Stress Incontinence Susannah Elvy Urogynaecology CNS
Definitions Prevalence Assessment Investigation Treatment Surgery Men
International Continence Society define as the complaint of any involuntary leakage of urine.
How many women are affected? EPINCOT 27,000 (2000) 25% suffer UI 7% significant leakage Risk increasing with age Underestimated 3 million women in UK < 20% receive any investigation Est 1 in 5 over 40 UK
Cost of Incontinence to the NHS England 1998 22.7 Drugs 58.6 69.0 Appliances Containment Products 13.3 189.9 Staff Costs & Direct Overheads Surgery 0 25 50 75 100 125 150 175 200 (Millions ) TOTAL 353.5m* TOTAL Est UK 423.5m* (*Excludes residential, nursing home or long-term hospital care due to incontinence)
Risk factors USI Childbirth Increased parity Age Obesity Chronic illness/lifestyle Medication Family history
Effect on the individual Psychological and physical Isolation Sexual issues Poor sleep Constipation Falls/fractures Skin problems
Assessment Key points to ask: What happens? How often? What doing at the time? How much urine? Pads? Urinalysis Rule out UTI/DM Post void residual Bladder diary Examination
Examination Digital assessment of pelvic floor muscles Obvious prolapse? Vaginal atrophy Urethral mobility Cough leak?
Pelvic floor assessment Laycock and Jerwood, 2001
Other tests Pad testing 1 hour 24 hour NICE not recommended Poor quality evidence/ reliable? Example Miss E
Lifestyle/behavioural changes Weight Cough/smoking Activity/ cognition Fluids Bowels
Pelvic floor muscle training Supervised Eight contractions, three times a day, 3 months minimum PFE increase strength and durability Increase UCP
Electrical stimulation Electrical stimulation and/or biofeedback should be considered in women who cannot actively contract pelvic floor muscles in order to aid motivation and adherence to therapy. NICE guidelines
Oestrogen cream Post menopausal Improve tissue Oestrogen receptors in urethra Strengthen collagen
Medication Duloxetine Serotonin and noradrenaline reuptake inhibitor Also called Yentreve Available as Capsules Side effects Nausea and vomiting Dry mouth Blurred vision Do not use duloxetine as a first-line treatment for women with predominant stress UI.. If duloxetine is prescribed, counsel women about its adverse effects Nice 2013
Manage
Urodynamics Multi-channel filling and voiding cystometry is recommended before surgery if: D O suspected previous USI surgery or anterior compartment prolapse Symptoms of? voiding dysfunction Not recommended in clear USI
MDT Consultant urogynaecologist / urologist Nurse specialist Womens health physiotherapist Continence service Colorectal
Surgery Bulking agents and injectables Tension free vaginal tape (TVT)/Transobturator tape (TOT) Colposuspension AUS
Surgery cont d The ideal surgical procedure urinary continence should Restore anatomy and function low complication rate long term results Improve quality of life cost effective? NICE
Urethral bulking
Urethral bulking USI Minimally invasive No incision Local anaesthetic Outpatient Collagen / micro beads Effectiveness declines 70% may need re-do! Suitable for older?
Comparison with other surgery Inferior to surgery at 12 months Better safety profile No comparison with pelvic muscle training Unproven effectiveness Useful where co-morbidity is a problem? Cochrane review 2003
Sling procedures - TVT tension free vaginal tape Most common sling procedure Intro mid 1990 s Minimally invasive Uncomplicated USI Synthetic mesh ribbon Support the urethra
Slings and tapes
Pre op Urodynamics - to confirm stress incontinence? Teach CISC
Tape - risks Voiding difficulties CISC 1.5% - 8% ( short term) New OAB (5%) Tape erosion Bladder injury
Transobturator tape Different surgical approach Obturator foramen TVT vs TOT no difference Less bladder injury Surgical preference
Colposuspension
Colposuspenion Gold standard 69% improved 20 years f/up 22% voiding difficulties post op Short term 5-15% develop DO / OAB 5% recurrent UTI s
Female AUS
Surgery for Stress Incontinence Trend towards less invasive surgery Reduced morbidity Shorter hospital stay Quicker return to work 2000-1 10,000 procedures carried out
Men USI Radiation Surgery post prostectomy PFMT pre op support post op Pads/Sheaths Surgery AUS/ Male sling
Post prostatectomy USI 10% at 1 year Average regain continence by 15/12 Age / severity effect Unpredictable
Conservative treatments PFMT (preop) No difference at 1 year?biofeedback Psychological support Pads and containment products
AUS 3 parts cuff, reservoir, pump Dexterity Preop information Compliance Risks of infection Failure to function Removal Cost /availability 75% 15yrs functioning device
Thank you