urinary incontinence victoria cook consultant in obstetrics and gynaecology the hillingdon hospital
TRANSCRIPT
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Urinary Incontinence
Victoria Cook
Consultant in obstetrics and Gynaecology
The Hillingdon Hospital
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Objectives
• Make a provisional diagnosis of cause of incontinence
• Formulate appropriate management plan
• When to refer
• Who to refer to
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Incontinence in Women
• Major impact on quality of life– Fear of cough / cold– Stop exercising– Avoidance of sex– Fear of odour– Worry about pads – cost, visibility, leakage– Limitations of clothing– Toilet mapping– Housebound
• Yet may take years to present for help– Embarassment– Acceptance that it is normal after having kids
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Definitions (ICS 2002)
• Over active bladder– Urgency with or without urge incontinence, usually
accompanied by frequency and nocturia
• Urge incontinence– Involuntary leakage accompanied by or immediately
preceded by urgency
• Stress incontinence– Involuntary leakage on effort or exertion or on sneezing
or coughing
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• Urgency: The complaint of a sudden, compelling desire to pass urine, that is difficult to defer
• Frequency: Usually accompanies urgency with or without urge incontinence. Refers to a patient’s complaint of voiding too often by day
• Nocturia: Usually accompanies urgency with or without urge incontinence. Patient has to wake at night one of more times to void
1. Abrams P et al. Urology 2003;61:37-49
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Differential diagnosis
Normal Bladder OAB Stress Incontinence
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Stress Incontinence or Overactive Bladder?
• Leakage– What makes her leak– how much– Pad usage
• Frequency of Micturition• Nocturia• Urinary Urgency• Bedwetting• Sex
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Stress Incontinence or Overactive Bladder?
• Examination– Abdominal mass– Pelvic mass– Prolapse– Leakage seen on coughing– Vulval hygiene
• Investigations– MSU– Frequency volume chart
• (Urodynamics)
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Management of Urinary Incontinence
• Behavior modification• Bladder retraining• Weight loss• Pelvic floor exercises• Fluid management – what, when, how much• Reduction in caffeine
• Bladder and bowel foundation – www.bladderandbowelfoundation.org– Just can’t wait toilet card (£5)
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Management of Overactive Bladder
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Treatment of Overactive Bladder
• Conservative measures• Review all other medication which may be
exacerbating symptoms– Diuretics– Amlodipine– Other antihypertensives
• Anticholinergics– Contraindicated with glaucoma
• (Botox)
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NICE GUIDANCE
• Treat predominant symptom• Oxybutynin Hydochoride
– Cheap– Works well– Side effect profile can be a problem– All other anticholinergics have been developed to improve
side effects
• Reasonable first line as long as – patient aware there are alternatives– Patient can be reviewed within 6 weeks to ensure they are
tolerating the drug
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Which Anticholinergic?
• (Detrusitol (tolterodine) 4mg XL)• Vesicare (solifenacin) 5mg or 10mg• Lyrinel (oxybutynin) XL 5mg, 10mg, 15mg or
20mg• Kentera (oxybutynin) patches• Emselex (darifenacin) 7.5mg or 15mg • Toviaz (fesoterodine) 4mg or 8mg
• Regurin (trospium) 20mg twice daily
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Which Anticholinergic?Vesicare 5mg increasing to
10mg if necessary and if tolerated
Lyrinel in increasing doses if no success
with Vesicare
Kentera if side effects a problem with
Vesicare
Emselex if IBS or bowel problems
Exacerbated by Vesicare
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Botox
• Unlicensed• Seems to be very effective• Multiple injections into the detrusor muscle via
cystoscopy• Evidence of long term safety in other disciplines• But needs repeat injections approx 12 monthly• Expensive!
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Treatment of Stress Incontinence
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Treatment of Stress Incontinence
• Life style advice
• Physiotherapy
• Duloxetine
• Surgery– TVT– Bulkamid bladder neck injections– Colposuspension
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Stress Incontinence
• Yentreve (duloxetine) – Start at 20mg twice daily– Increase to 40mg twice daily after 2 weeks– This is to reduce side effects– It is working at level of urinary sphincter– NOT by reducing depression!– Patients either love it or hate it
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Surgery
• TVT– Over night stay– Good success rates 80-90%– 2 weeks off work– Risks of urgency, poor voiding, tape erosion
• Bulkamid– Bladder neck injection – polyacrylamide hydrogel– Day case / overnight stay– Long term results unknown– Useful in mixed incontinence, young, old, failed TVT
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Mixed Incontinence
• Lifestyle advice
• Physiotherapy
• Treat overactive bladder
• Duloxetine can be very useful
• I try to avoid surgery as they do badly
• Now using Bulkamid – time will tell!
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When to Refer
• Overactive bladder– If patient not responding or unable to tolerate
anticholinergic (oxybutynin plus one other)
– Glaucoma
• Stress incontinence– If patient doesn’t respond to pelvic floor exercises
(preferably with physiotherapist)
• Prolapse• Other factors
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Who To Refer To?
Urogynaecology
Prolapse FibroidsOther gynae issues
Urology
NeurologyBotox
Bladder painOther pathology
Both
Stress incontinenceOveractive bladder
Recurrent UTI