Female Urinary Incontinence

Dr Blayne Welk

Assistant Professor, Division of Urology, Western University

Disclosures Female Urinary Incontinence

Presenter Disclosure:

Dr Blayne Welk has no potential for conflict of interest with

this presentation (but has received funds from Astellas, Pfizer,

and Allergan).

Objectives

Review 3 key facts about urinary incontinence

Review 4 key things to do when evaluating a woman

with incontinence

Discuss the treatment options available to you as a family

physician

Review the treatment options available to specialists

Urinary Incontinence

Fact 1: Types of Urinary Dysfunction

22

American Urological Association

permanent catheter placements also should be followed regularly for symptom level, QoL and any complications. Patients who are using incontinence

pads, regardless of whether or how they are being treated, should be followed for appropriate skin care

and skin integrity.

Section 7: Research Needs and Future Directions

Better Stratification of OAB. OAB, because it is a

symptom complex, is primarily a diagnosis of exclusion.

Treatments are aimed at relieving symptoms and not

necessarily at reversing pathophysiologic abnormalities. Understanding the pathophysiology and the risk factors

for development of OAB is needed both to treat the syndrome as well as to prevent it. Future research will

need to address the entire spectrum of research

endeavors including epidemiology, QoL measurements, treatment modalities and basic bladder physiology

including sensory and motor signaling. Within the field of OAB, research sometimes is dichotomized between OAB/lower urinary tract symptoms or LUTS (e.g., OAB-

dry) versus OAB/urgency incontinence (OAB-wet).

However, this type of compartmentalization highlights our lack of understanding of OAB. In other words, are

OAB-dry and OAB-wet pathophysiologically related? Is

OAB-dry a milder manifestation of the OAB condition which progresses to OAB-wet over time? Or are OAB-

dry and OAB-wet two different conditions with different pathophysiologic mechanisms? How can we better

objectively measure bladder symptoms? In addition, particularly in females, stress urinary incontinence

(SUI) symptoms may exist concomitantly with OAB-symptoms (dry or wet). Further, isolated nocturia is a separate symptom entity, requiring different evaluation

and management strategies. This overlap in bladder

symptoms is captured in the Venn diagram below with

their potential to be concomitantly present. This Venn diagram will appear different based on the gender and age of the population depicted; the diagram included here is intended to provide a point of reference for

discussion. Therefore, the phenotype of bladder

symptoms should be carefully considered and declared

in all research to clarify the particular patient group being studied.

Epidemiology. Studies assessing how OAB develops

and its natural history and progression are required. The timing and circumstances around which OAB

develops and associated risk factors are not yet well-

u n d e r s t o o d .

While not specifically

targeting epidemiology of OAB, there are large community-based studies that assess prevalence of

lower urinary tract symptoms and urinary

incontinence.200, 201 By longitudinally studying these community cohorts, these investigators have developed

a new hypothesis that lower urinary tract symptoms are likely related to other systemic diseases/conditions.202,

203 Continuation of these types of studies could lead to potential preventive interventions for OAB symptoms

and/or utilization of treatments that target the

associated systemic conditions rather than the bladder. Epidemiologic studies provide a better cross sectional

estimation of the overall population impact of OAB-type symptoms.204

Clinical Research. As discussed previously, several validated OAB-symptom and OAB-symptom bother

tools have been developed. However, objective

measures   of   the   “cornerstone”   OAB-symptom of urgency205 remains poorly assessed. As defined by the

International Continence Society,27 “urgency   is   the  

complaint of a sudden compelling desire to pass urine

which  is  difficult  to  defer.”    Investigators  have  tested  urgency questionnaires to assess for validity and

reliability;206-208 however, no single measure is used

consistently across trials, making it difficult to compare

findings.

Clinical studies should use validated standardized

measures to report subjective outcomes. Objective

outcomes should include frequency, nocturia, urgency, incontinence episode frequency and reporting of the variance for each of these measures. Furthermore, the

Overactive Bladder

OAB-dry

OAB-wet

SUI

Isolated nocturia

unrelated to OAB

Textured circles – incontinent subjects

Non-textured circles – continent subjects

Future Directions

Copyright  ©  2012  American  Urological  Association  Education  and  Research,  Inc.®

Nocturia Others:

• Fistula

• Overflow retention

10-40% of the

female

population

Fact 2: Why do women get

Incontinence?

Stress incontinence

Age

Ethnicity

Vaginal delivery

Genetics (40% of the

problem!)

Obesity

Smoking

Urgency Incontinence

Age

Ethnicity

Vaginal delivery

Genetics (only for Urgency

incontinence, not OAB!)

Obesity

Caffeine

Fact 3: Reversible causes of

Incontinence

Delirium or Drugs

Alcohol, Caffeine, Diuretics

Restricted mobility

Infection, impaction

Polyuria

Delirium

Infection

Atrophic

Pharmacologic

Psychological

Excess urine

Restricted Mobility

Stool Impaction

“DRIP” “DIAPERS”

Evaluating a woman for incontinence

Task 1: What kind of incontinence does

she PRIMARILY have?

Stress incontinence

Involuntary leakage on effort or exertion, such as sneezing or

coughing

Urgency incontinence

Involuntary leakage accompanied by or immediately

preceded by urinary urgency

The challenging ones…

“I leak all the time”

“I leak day and night”

“I have large volumes of incontinence”

Probably urgency incontinence

“I leak after I am done voiding”

Post void dribbling

ICIQ-UI Short Form

More questionnaires…

Task 2: Red Flags

Hematuria

Full bladder

Beware the radiologists PVR!

Other pelvic mass

Neurologic disease/symptoms

Back pain & lumbar disc disease

Recent urologic/gynecologic surgery

Urologist

Urologist

Gynecologist

Urologist/Neurologist

Neurosurgery

Followup Apt

Task 3: Examination

Palpable bladder

Screening neurologic exam of the lower limbs

Vaginal exam

Vaginal atrophy

Cystocele

Rectocele

Cough test

Bimanual

Task 4: Investigate

Urinalysis (+ Culture if suspicious)

Pelvic US with PVR (maybe)

Voiding diary

DAY 4 Date:

Time Amount Voided

(in ccs) Leak Volume (scale of 1-3*)

Activity during leak Was there an urge Fluide intake

(Amount in ounces/type)

Patient Name:

Instructions:

1. Choose 4 days (entire 24 hours) to complete this record – they do not have to be in a row. Pick days in which will be convenient for you to measure every void. 2. Begin recording when you wake up in the morning–continue for a full 24 hours. 3. Make a separate record for each time you void, leak, or have anything to drink. 4. Measure voids (using cc measurements) using the hat. 5. Measure fluid intake in ounces. 6. When recording a leak – please indicate the volume using a scale of 1-3 *(1=drops/damp, 2=wet -soaked, 3=bladder emptied), your activity during the leak, and if you had an urge (“yes” or “no”).

Normal voiding diary results

What to recommend for your patient

Option1: Behavioral/lifestyle changes

Conservative options

Reduce caffeine, fluid intake, or change the times they are taken

Review medications (ie diuretics)

Pessaries

Incontinence vs prolapse

Treat constipation

Quit smoking

Weight loss

NEJM RCT demonstrated that an 8% weight loss translated into a 47% reduction in incontinence

Bladder training: more frequent voiding

Bladder training

Schedule based on an interval the patient can manage

in daytime

Void at scheduled time even if urge not present; suppress

the urge if not time with Kegels

Increase voiding interval by 30 min each week until

continent for 3-4 hr

Option 2: Pelvic floor therapy

Pelvic floor muscle therapy

Primarily effective for both stress incontinence

Strengthening

Also effective for urgency incontinence

Urge suppression (10sec contraction, or 5 rapid contractions)

30% of women do Kegel’s wrong

Easy! Referral to a pelvic floor physiotherapist in London

Centric Health Physiotherapy and Wellness

www.lifemark.ca

Family Physiotherapy Centre of London

fpclondon.com

Option 3: Estrogen

Oral Estrogen

Not helpful!

Women's health initiative study (RCT, 23,000 women)

18% higher risk of incontinence (mostly stress

incontinence)

Vaginal estrogen

May improve incontinence, especially urgency

incontinence

Probably improves urgency and frequency

Probably works best if there is vaginal atrophy

Option 4: Oral medications

Only for mixed or urgency incontinence

Multiple approved medications available

All better than placebo

Modest effectiveness

Reduce urgency incontinence by 50%

Reduce frequency and urgency episodes by a few/day

Improved urinary quality of life

1-2/10 women become completely continent

Anticholinergics versus B3 agonists

The evidence based conclusions

about anticholinergics

Extended release oxybutnin has less dry mouth than IR

oxybutnin

Tolterodine is better tolerated than oxybutnin

Solifenacin has better cure/improvement than Tolterodine

Fesoterodine has better cure/improvement than Tolterodine

Solifenacin and Fesoterodine have titratable efficacy

Madhuvrata P, Cody JD, Ellis G, Herbison GP, Hay-Smith EJC. Which anticholinergic drug for overactive bladder symptoms in adults. Cochrane Database Syst Rev. 2012.

Specialist Management Stress Urinary incontinence

Bulking agents

Specialist Management Stress Urinary incontinence

Midurethral sling

Specialist Management Stress Urinary incontinence

Autologous fascial pubovaginal sling

Specialist Management Stress Urinary incontinence

The future

Intraurethral injection of autologous stem cells

Mini-slings

Specialist Management Urgency incontinence

Intravesical botox

Specialist Management Urgency incontinence

Neuromodulation

Specialist Management Urgency incontinence

The future

New drug targets in the bladder

Conclusions

Very few women with incontinence require an operation

Many women can be managed with reassurance and behavior modification

Pelvic floor muscle therapy is a good option for a motivated patient

A trial of anticholinergic medication is appropriate for patients with urgency or mixed incontinence

Multiple options are available for women if initial therapies aren’t effective, and they are bothered by their symptoms