Urinary Incontinence. Lora Keeling and Byron Neale

Transcription

1 Urinary Incontinence Lora Keeling and Byron Neale

2 Not life threatening. Introduction But can have a huge impact on quality of life. Two main types of urinary incontinence (UI). Stress UI leakage on effort, exertion, coughing etc. Urge UI leakage with strong desire to urinate. Often a mixed pattern of stress UI + urge UI. Overactive bladder syndrome (OAB) = urgency ± urge UI usually with frequency and nocturia.

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4 History and Examination Ask about incontinence impact, role limitations, social limitations, relationships, emotions, sleep, symptom severity. Determine if stress or urge incontinence. This can be established from history. Exclude UTI and diabetes (dipstick). Stress UI may see prolapse or urinary incontinence on cough (sims). Examine for prolapse and digital assessment of pelvic muscle power.

5 Initial Management Diagnosis usually possible from history and examination. NICE recommends asking patient to complete a symptom diary for 3+ days covering variations in usual activity (work, leisure). Lifestyle advice reduced fluid intake (esp caffeine) and reduction in weight if BMI >30. Treat UTI if symptoms and on dipstick results.

6 Conservative Management Determine if urge or stress UI predominant problem Urge UI bladder training 6+ weeks (add antimuscarinic if frequency still a problem e.g. oxybutynin, tolterodine) Stress UI pelvic floor muscle training 3+ months (8 contractions, 3 times a day)

7 Surgical Management (SUI) Prior to surgery: urodynamic studies can be used if suspect detrusor overactivity, voiding dysfunction or previous surgery. Duloxetine (SNRI) alternative to surgery in stress UI. Three operative choices: Tension free vaginal tape (retropubic) (TVT). Transobturator tape (TVT-O). Burch colposuspension.

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9 Surgical Management (SUI) Other alternatives include intramural bulking agents. Effectiveness decreases over time. Repeated injections needed. Less effective than surgery. Artificial urinary sphincter. Only used if previous surgery has failed.

10 Management (UUI) If conservative management fails: Sacral nerve stimulation. Augmentation cytoplasty. Urinary diversion (if above failed). Cystodistension (rarely used). Botulinum toxin (only suitable if no response to conserative management and patient prepared to self catheterise).

11 Case Study 38 year old parous woman notices incontinence during exercise and when coughing. Had problem for 8 years since the birth of her daughter (forcept delivery). Needs to wear sanitary protection continuously. No difficulty urinating. Voiding 5-6 times and day and once at night (normal!).

12 Likely diagnosis: Urinary stress incontinence. Other possibilities include: mixed incontinence, urge incontinence or a neurological disorder. History pointers to support: Involuntary urine loss on raised abdominal pressure. No voiding difficulties. Forceps delivery risk factor. Quality of life impact. No obvious urge incontinence. Uterovaginal prolapse / faecal incontinence association.

13 Clinical examination: Physical examination with comfortably full bladder. Incontinence demonstrated by cough. May see uterovaginal descent on strain. Investigations: Urine dipstick to check for infection, diabetes. Bladder diary evaluate fluid intake and record episodes of urgency. Urodynamic investigations if detrusor overactivity suspected.

14 Urodynamic investigations (a) Normal bladder no detrusor contraction, no urine flow with cough. (b) Stress incontinence no detrusor contraction, urine flow with cough. (c) Urge incontinence detrusor contraction after cough, urine flow if bladder pressure sufficient to overcome urethral pressure.

15 Appropriate treatment Supportive pelvic floor re-education. Surgical TVT, TVT-O, colposuspension, wall bulking.

16 Sources NICE 2006, Urinary Incontinence, NICE clinical guideline 40 [ nglish] accessed Feb Mires G, Khan K, Gupta, Core clinical cases in obstetrics and gynaecology. 3 rd Ed. Hodder Arnold. Impey L, Child T, Obstetrics & Gynaecology. 4 th Ed. Wiley-Blackwell.