Urinary Incontinence. Vibhash Mishra Consultant Urological Surgeon Royal Free Hospital

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1 Urinary Incontinence Vibhash Mishra Consultant Urological Surgeon Royal Free Hospital

2 Affects women of all ages Impacts physical, psychological & social wellbeing Impact on families & carers Costs the NHS 233 million/yr

3 4 million incontinent women >40 in UK 10% - 26% of adult females & 8% - 42% of adult males Annual incidence 2% - 11% among females, 4% - 6% among males

4 The concept of Lower Urinary Tract (LUT)

5 LUT: Function Preservation of upper tracts by low pressure storage of urine with continence and low pressure voiding to completion

6 LUT: Function Storage Bladder relaxation, sphincter contraction Voiding Bladder contraction, sphincter relaxation

7 Urine stored when sympathetic nerves active Sympathetic agonist (Mirabegron) = continence

8 Parasympathetic stimulation causes voiding Anticholinergics = continence

9 Transmitters/Receptors Parasympathetic Ach M3 Detrusor contraction, urethral relaxation Sympathetic NE β3 Detrusor relaxation, urethral contraction

10 Incontinence: Failure storage Inappropriate bladder contraction &/or sphincter relaxation during storage

11 Incontinence: Types Essentially two types Inappropriate bladder contraction/detrusor overactivity/urge incontinence Inappropriate sphincter relaxation/sphincter weakness/stress incontinence

12 Urge Incontinence: Possible causes Neurogenic CVA, MS, SCI etc. Idiopathic (non-neurogenic) True idiopathic (no known cause) Bladder pathology (UTI, stone, obstruction etc.)

13 Stress incontinence: Possible causes Weakness of pelvic floor (women) childbirth, connective tissue failure Trauma (usually iatrogenic) Prostate surgery (men) Neurological

14 Evaluation - Hx What type? How bothered? Anything sinister? Trigger exertion or urgency Ever leak at night or when not physically active? DIAPPERS (Delirium, inf, atrophy, pharma, psychological, excess UO, mobility, stool impaction) Cognition, manual dexterity Pitfalls

15 Bother is important: equally incontinent but who is more bothered

16 Pitfalls (Red flags) Haematuria UTI Bladder pain Recent/relatively sudden onset Very young pt (possible neurology) Voiding LUTS &/or large PVR Sterile pyuria

17 Evaluation - Examination Full bladder cough/valsalva Manual dexterity

18 Evaluation - Ix Urinalysis Flow PVR Bladder diary nocturnal polyuria Urodynamics

19 Pitfalls (Red flags) Haematuria UTI Bladder pain Recent/relatively sudden onset Very young pt (possible neurology) Voiding LUTS &/or large PVR Sterile pyuria

20 Management: Factors to consider

21 Management: Factors to consider General health/cognition/dexterity Social circumstances Common sense/flexibility Patient preference/bother

22 Management general Precipitating factors Unsafe upper tracts? overflow, neurological conditions urgent attention Safe upper tracts convenience/preference

23 48 yr-old woman with F, U, N & UUI what will be your initial management?

24 Urge incontinence: Initial management Behavioral therapy Weight, Fluid, Alcohol/caffeine/smoking Continence advise Bladder retraining, Pelvic floor exercises at least 6/52 Pharmacotherapy

25 Pharmacotherapy Mode of action of OAB treatments 1,3 M3 β3 [+] [-] Adapted from Betmiga Summary of Product Characteristics, December and Chu et al., Betmiga Summary of Product Characteristics, December Gras J. Drugs of Today 2012;48(1): Chu F, Dmochowski R. Am J Med 2006;119(3A):3S 8S. Date of preparation: February BET13018UK

26 Urine stored when sympathetic nerves active Sympathetic agonist (Mirabegon) = continence

27 Parasympathetic stimulation causes voiding Anticholinergics = continence

28 Pharmacotherapy Achieve bladder relaxation M3 antagonist/anti-muscarinic/anticholinergic β3 agonist

29 Pharmacotherapy: Anti-muscarinics Tertiary Amines Tolterodine Solifenacin Fesoterodine Darifenacin Quaternary Amine Trospium chloride (no effect on cognition) Anti-muscarinics with mixed actions Oxybytynin (direct muscle relaxation) Popiverine ( Ca influx musculotropic spasmolysis) Other drugs with anti-muscarinic action Tricyclic antidepressants ( Ca translocation, direct relaxation, sedation, reuptake of NE)

30 No help with first line T/t what next?

31 No help with first line T/t what next? Higher dose? Different anti-muscarinic Combination T/t Mirabegron

32 Pharmacotherapy Mode of action of OAB treatments 1,3 M3 β3 [+] [-] Adapted from Betmiga Summary of Product Characteristics, December and Chu et al., Betmiga Summary of Product Characteristics, December Gras J. Drugs of Today 2012;48(1): Chu F, Dmochowski R. Am J Med 2006;119(3A):3S 8S. Date of preparation: February BET13018UK

33 Pharmacotherapy: Anti-muscarinics Tertiary Amines Tolterodine Solifenacin Fesoterodine Darifenacin Quaternary Amine Trospium chloride (no effect on cognition) Anti-muscarinics with mixed actions Oxybytynin (direct muscle relaxation) Popiverine ( Ca influx musculotropic spasmolysis) Other drugs with anti-muscarinic action Tricyclic antidepressants ( Ca translocation, direct relaxation, sedation, reuptake of NE)

34 Urge incontinence: Further management +/- Urodynamics Botox PTNS/Acupuncture Neuromodulation Bladder augmentation Diversion (SPC/Conduit)

35 Botox V SNM at 6 months Botox SNM Number Reduction in mean daily UUI episodes % reduction in UI 60-65% 51-52% Pads/day Treatment satisfaction 68% 60% Treatment preference 92% 89% PGI-I Urine leak 71% 68% Bladder function 68% 70%

36 Urge Urinary Incontinence Sacral Neuromodulation Versus Botox 1,2 2 year outcomes of a multicentre RCT comparing sacral neuromodulation and OnabotulinumtoxinA Initial 6 month results showed greater reduction in urgency incontinence episodes with botox (p= 0.01) At 2 years differences between groups reduced with equivalent rates of complete resolution (5%) and >75% reduction (21%-22%) Botox group did have higher satisfaction and endorsement scores despite higher rates of recurrent UTI Low rates of CISC after botox (6%) and SNM revision (3%)/ removal (9%) Amundsen CL, Richter HE, Menefee SA, et al. OnabotulinumtoxinA vs Sacral Neuromodulation on Refractory Urgency Urinary Incontinence in Women: A Randomized Clinical Trial. JAMA 2016;316(13): doi: /jama Amundsen CL, Komesu YM, Chermansky C, et al. Two-Year Outcomes of Sacral Neuromodulation Versus OnabotulinumtoxinA for Refractory Urgency Urinary Incontinence: A Randomized Trial. Eur Urol 2018;74(1): doi: /j.eururo

37 55 yr-old lady with SUI initial management?

38 Stress incontinence: Initial management Manage precipitating factors Weight optimisation Pelvic floor exercises (3/12)

39 No better with PFE what next?

40 Stress incontinence: Further management +/- VCMG Mid-urethral tape (TVT/TOT) Colposuspension Autologous sling?bulking agent Diversion (SPC/Conduit)

41 Alternatives to tapes - colposuspension Cochrane Review of Colpo (2017) Open colpo an effective form of treatment Overall continence rate 85-90% within first yr, dropping to ~70% at 5 yrs Similar results to tapes Causes more POP but less vluts than tapes Does not talk much about chronic pain, dyspareunia etc.

42 Alternatives to tapes - PVS Not much recently on PVS E-SISTEr: 5-yr F/U of women from SISTEr trial (Burch v PVS) Continence rate at 5 yrs: 24% v 31% Satisfaction rate at 5 yrs: 73% v 83% AEs: 10% v 9% - AEs mostly related to UTIs, no serious AEs Brubaker, Richter, Norton et al. Five year follow up of Burch & fascial sling surgery for UI. J Urol 2012; 187 (4):

43 Alternatives to tapes urethral bulking Bulkamid early days! 70-80% cured or improved at 12/12 Efficacy sustained at 5-7 yrs Caution repeat treatment, attrition, efficacy inferior to other forms of treatment

44 Summary Urge incontinence Beware of pitfalls +/- bladder diary BT, PFE & Ach/Mirabegron Further Ix & invasive T/t SUI Weight optimisation & PFE Further Ix & surgery

45 Thank you