Various Types. Ralph Boling, DO, FACOG

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1 Various Types Ralph Boling, DO, FACOG

2 The goal of this lecture is to increase assessment and treatment abilities for physicians managing urinary incontinence (UI) patients. 1. Effectively communicate with and assess individuals for symptoms UI 2. Diagnose and characterize individuals with urinary symptoms. 3. Develop a management plan for individuals with a diagnosis of UI

3 Urinary incontinence, the involuntary leakage of urine, often goes undetected by clinicians. Even when aware of incontinence, clinicians often do not treat adequately.

4 Stepwise treatment strategies should be discussed with the patient.

5 For most individuals, primary care clinicians can identify the appropriate causes of incontinence and initiate treatment. Specialized testing and referral to a specialist are required in only a minority of cases

6 Urgency a sudden and compelling desire to pass urine Daytime frequency the need to void often during the day Nocturia waking up more than once at night to void Nocturnal enuresis nocturia associated with incontinence Slow stream the perception of reduced urine flow compared to baseline Intermittent stream or intermittency urine flow which starts and stops

7 Hesitancy difficulty in initiating voiding Straining to void increased muscular effort used to initiate, maintain, or increase the urinary stream Incomplete emptying the sensation that the bladder is not empty after voiding Continuous urinary incontinence continuous leakage, usually dribbling, of small amounts of urine

8 urgency incontinence typically have symptoms of involuntary leakage of urine accompanied by urgency Common triggers include running water, hand washing, and cold weather exposure caused by detrusor overactivity.

9 stress incontinence have involuntary leakage of urine that occurs with effort, exertion, sneezing, coughing, laughing, or anytime an increase in intraabdominal pressure exceeds urethral sphincter closure mechanisms Stress incontinence is the most common type of urinary incontinence in younger women often coexists with urgency incontinence

10 Elements of stress and urgency presenting together.

11 Overflow incontinence is involuntary, continuous, urinary leakage or dribbling and incomplete bladder emptying caused by impaired detrusor contractility or bladder outlet obstruction significant pelvic organ prolapse

12 involuntary detrusor contractions or overactivity, decreased detrusor contractility, low estrogen levels, changes in fluid excretion patterns, and decrease in urethral closure pressure Other urologic or gynecologic disorders Fistula, Interstitial Cystitis, Prolapse

13 Congestive heart failure: Nocturia is often present Neurologic disorders: Manifestations of stroke, multiple sclerosis, Parkinson disease, disc herniation, spinal cord injury, normal pressure hydrocephalus, or subacute combined degeneration may be present. Diabetes mellitus, insipidus.

14 Cancers: Urinary frequency can occur in women with urethral cancers. Hematuria with bladder cancer

15 The initial evaluation includes a thorough history, physical examination, and urinalysis. Additional evaluation is warranted in the presence of complex medical conditions or worrisome findings on history and physical examination. bladder stress test, postvoid residual), additional laboratory tests, radiographic imaging, and referral to a specialist

16 Do you ever leak urine/water when you don t want to? Do you ever leak urine when you cough, laugh, or exercise? Do you ever leak urine on the way to the bathroom? Do you ever use pads, tissue, or cloth in your underwear to catch urine?

18 The cardiovascular examination The abdominal examination The extremities The neck examination The detailed pelvic examination A neurologic examination must be performed in patients with sudden onset of incontinence (especially urge), known neurologic disease, or new onset of neurologic symptoms

19 Bladder stress test The bladder stress test is performed by asking the patient, with a full bladder, to stand, relax, and give a single vigorous cough. A pad is held underneath the perineum and the clinician observes directly whether there is leakage from the urethra Postvoid residual volume The Fourth International Consultation on Incontinence recommends against postvoid residual (PVR) testing as part of the initial evaluation, and there are no high-quality data from randomized trials to support routine testing

20 Behavioral and lifestyle changes that may reduce the risk for urinary incontinence include weight loss for obesity, smoking cessation, increasing physicalactivity/exercise, and improving diet. Pelvic floor muscle exercises and biofeedback are effective in preventing and reversing some urinary incontinence in the first year after vaginal delivery or following pelvic surgery. Pelvic floor muscle exercises also decreased the one-year risk of developing incontinence in older women. Management of conditions associated with incontinence (eg, diabetes, neurologic conditions, impaired mobility, depression, constipation, and urinary urgency) may prevent incontinence or improve the effectiveness of management. Specific medications and surgical procedures may adversely affect continence, and clinicians should include these risks in discussing treatment choice with patients.

21 Patients should be advised to drink an adequate amount of nonalcoholic fluid, usually six cups daily, or more when temperatures are high or when exercising. Most individuals empty the bladder approximately every three to four hours during the day; getting up once during the night to void is acceptable in older persons. It is important to relax and not strain when voiding or moving the bowels. Keeping bowel movements regular through adequate fiber intake, hydration, and exercise is important for healthy urinary voiding.

22 Contributory factors such as medical conditions and medications should be addressed before proceeding with the treatment approach described here. Our initial treatment approach for all patients with urinary incontinence includes lifestyle changes (dietary changes, weight loss for stress incontinence) and behavioral therapy (bladder training, pelvic muscle exercises).

the literature but without supporting evidence include: citrus juice and fruits, tomatoes

23 Weight loss, if obese Dietary changes Alcoholic beverages Carbonated beverages (with or without caffeine) Coffee or tea (with or without caffeine) Other food groups mentioned in the literature but without supporting evidence include: citrus juice and fruits, tomatoes and tomato-based products, spicy foods, artificial sweetener, chocolate, corn syrup, sugar or honey

24 Behavioral treatments (bladder training and pelvic muscle exercises [PME] Kegel s) are effective for urgency, stress, and mixed urinary incontinence, and may help patients with overactive bladder symptoms, with or without incontinence. They should be the initial treatment for patients with mild to moderate leakage, and remain an option for patients with more severe symptoms. Bladder training and pelvic muscle exercises are often used in combination. Behavioral methods can be at least as effective as drug therapy for urgency incontinence. In one trial of older women with urge and mixed urinary incontinence, behavioral therapy with biofeedback reduced accidents by 81 percent, compared with 69 percent for oral oxybutynin

25 Urgency and mixed incontinence Antimuscarinics 10 % efficacy Since differences in efficacy are not compelling, the choice of antimuscarinic for an individual depends on cost, dosing frequency, drug-drug interactions, potential side effects, and comorbid conditions that may increase adverse drug effects. Head-to-head comparison trials consistently show that extended-release agents have lower rates of adverse effects than immediate release agents.

26 Antimuscarinics can take up to four weeks to reach their full efficacy, indicating that clinicians should avoid escalating the dose or declaring treatment failure prematurely. The quick onset of action of the immediate release preparations makes them useful when continence is desired at specific times. Patients may respond to one antimuscarinic and not another.

27 A modest benefit is seen with the betaagonist mirabegron injection of botulinum toxin into the detrusor muscle is an option

Acupuncture is used sometimes as an alternative to antimuscarinic therapy for patients who prefer a complementary medicine approach to treatment of urinary incontinence, but there is insufficient

28 Acupuncture is used sometimes as an alternative to antimuscarinic therapy for patients who prefer a complementary medicine approach to treatment of urinary incontinence, but there is insufficient evidence regarding this therapy. For urgency and mixed incontinence, initial pilot studies of using acupuncture for the treatment of urgency and mixed urinary incontinence have shown some positive shortterm improvements in quality of life measures and reduction in urinary frequency.

29 For stress incontinence that is not sufficiently relieved by behavioral therapy, based on the patient s goals of treatment and personal preference, we would intensify modification of lifestyle factors and behavioral therapy, or refer for consideration of surgical treatment

30 Estrogen There is some evidence regarding the utility of vaginal estrogen therapy (vaginal creams, rings, tablets) for incontinence symptoms. A systematic review included four randomized trials that addressed this issue, and found that vaginal estrogen therapy modestly improved symptoms of stress incontinence (absolute risk reduction ). We typically use vaginal estrogen to treat urinary incontinence only if the patient has concurrent symptoms of vaginal atrophy.

31 Long-term adherence to antimuscarinic medications is generally low, and most patients with urinary incontinence do not have total relief of symptoms. Combined behavioral and pharmacologic therapy has been proposed to improve urge incontinence symptoms. However, randomized trials have not found combined therapy to be more effective than pharmacologic therapy alone

Patients with persistent urgency incontinence symptoms despite an adequate trial of standard treatment (lifestyle changes, behavioral therapy, and an adequate trial of antimuscarinics for at least

32 Patients with persistent urgency incontinence symptoms despite an adequate trial of standard treatment (lifestyle changes, behavioral therapy, and an adequate trial of antimuscarinics for at least six weeks at the maximally tolerated dose), or an inability to tolerate pharmacologic therapy, can be referred to a specialist, depending on the patient s goals of care. The specialist may consider the following: onabotulinumtoxina injections, neurologic stimulation therapy, or surgery. The risks and benefits of these options need to be discussed in the context of the individual s treatment goals

33 Electrical stimulation Electrical stimulation devices to treat urinary incontinence are thought to stimulate pelvic muscle contractions and/or modulate detrusor contractions. Electrical stimulation therapies for UI include: noninvasive electrical stimulation, sacral nerve stimulation (SNS) via surgically implanted electrodes, percutaneous stimulation of peripheral tibial nerve, and intravesical stimulation

Surgery offers high cure rates for stress urinary incontinence, even in older women. A trial of conservative therapy makes sense for most women.

34 Surgery offers high cure rates for stress urinary incontinence, even in older women. A trial of conservative therapy makes sense for most women. Surgery is potentially morbid, but minimally invasive procedures are available and should be offered to women who fail or decline conservative therapy. Vaginal procedures include: midurethral sling, bladder neck sling, or injection of urethral bulking agents. Burch retropubic colposuspension is an abdominal procedure for stress urinary incontinence.

35 These can be useful, as a non-surgical approach, as well, as an adjunct or in place of Pelvic muscle exercises (kegel s).

For the management of urinary incontinence, we prefer a stepwise approach: lifestyle changes and behavioral therapy followed by pharmacologic therapy.

36 For the management of urinary incontinence, we prefer a stepwise approach: lifestyle changes and behavioral therapy followed by pharmacologic therapy. With botulinum toxin A injections, neurologic stimulation therapy, or surgery considered only for patients who do not have an adequate response to noninvasive treatments

Incontinence: Risks, Causes and Care

Welcome To Incontinence: Risks, Causes and Care Presented by Kamal Masaki, MD Professor and Chair Department of Geriatric Medicine John A. Burns School of Medicine, UH Manoa September 5, 2018 10:00 11:00