1. The Problem Bladder: UTI, the Unstable bladder and Mixed Incontinence Stephen Jeffery/Pieter Kruger Groote Schuur Hospital UCT Private Academic Hospital

2. How do you define happiness? At age 4Not wetting your bed At age 10Having friends At age 18Having a driver’s licence At age 21Having sex At age 30Having money At age 65Having money At age 75Having sex At age 80Having a driver’s licence At age 85Having friends At age 90Not wetting your bed

3. Incontinence: Classification Urethral Stress incontinence Stress incontinence Overactive (unstable) bladder Overactive (unstable) bladder Mixed incontinence Mixed incontinence Voiding dysfunction Voiding dysfunction Congenital Congenital Functional FunctionalExtra-urethral Congenital Congenital Fistula Fistula

4. Incontinence: Classification Urethral Stress incontinence Stress incontinence Overactive (unstable) bladder Overactive (unstable) bladder Mixed incontinence Mixed incontinence Voiding dysfunction Voiding dysfunction Congenital Congenital Functional FunctionalExtra-urethral Congenital Congenital Fistula Fistula

5. Stress 49% 2 Urge 22% 2 Mixed 29% 2

6. Overactive Bladder Symptom syndrome consisting of urgency, with or without urge incontinence, usually with frequency and nocturia, in the absence of proven infection or other obvious pathology

7. Urgency Key symptom Sudden compelling desire to void that is difficult to defer

8. Millions are Suffering in Silence Austin et al. Western European Market & Media Fact 2001; IMS Data 2001 Milsom I et al. BJU Int. 2001;87:760-766 Estimated 49 million people in Europe aged >40 suffer from OAB Untreated OAB Sufferers Treated OAB Sufferers Estimated 293 million people >40 years old in Europe 44 million out of 49 million OAB sufferers in Europe are currently not being treated

9. Impact of OAB 30% increase in falls (Brown et al) Increase in stress and depression (Kobelt et al) Greater impact than Diabetes on QOL (Samuelson) Annual cost 3.98 Billion Euros (Germany) 3% of women change jobs due to OAB (Diokno)

10. What about Stress Incontinence? Stress incontinence is an involuntary loss of urine that occurs during physical activity, such as coughing, sneezing, laughing, or exercise

11. Clinical approach to the incontinent woman

12. Approach Important symptoms – Nocturia – Frequency – Urgency / urgency incontinence – Stress incontinence – Significant bothersome prolapse

13. Approach Red flag symptoms – Voiding difficulties – Haematuria – Severe bladder pain

14. Approach General Medical History – Multiple sclerosis – Parkinsons – Stroke

15. Approach Surgical History – Previous incontinence surgery – Previous vaginal surgery

16. Medications That May Cause Incontinence Diuretics Antidepressants Antihypertensives Hypnotics Analgesics Narcotics Sedatives OTC sleep aids and cold remedies

17. Approach Assess for pelvic floor dysfunction Look for leakage on coughing Urogenital prolapse Atrophy

18. Approach Assess for pelvic floor dysfunction Faecal Urgency Faecal Incontinence Defaecatory difficulty

19. Aims of Investigation Exclude undelying organ specific related or unrelated conditions that would require intervention Assess the level of bother and desire for intervention Institute empiric or disease specific therapy Prompt appropriate referral for more complex testing

20. Urinalysis Pyuria 60% of women with stable bladder will have DO Glycosuria DM – Peripheral autonomic neurop, UTI Haematuria Urothelial Ca

21. Post Void Residual Use a catheter Can use an ultrasound machine

22. Diary Frequency episodes Intake & output Bladder capacity Exclude 24 h polyuria (DI) & nocturnal polyuria

23. Standard Therapy Options for the Overactive Bladder Behaviour Modification Anticholinergics

24. Behavioural Modification Education Delayed voiding Timed voiding Reinforcement Pelvic floor exercises

25. Immediate release Oxybutynin Ditropan® Lendrito® Merck-Oxybutynin Chloride® Sandoz-Oxybutymin HCl ® Urihexal® Dose 2.5mg BD to 5mg qid Anticholinergics availalble in South Africa

26. Oxybutynin SR Lyrinel® Dose 5,10, 15 or 20mg per day Tolterodine Detrusitol SR® Dose 2 or 4mg per day Trospium Uricon® Dose 20mg BD Anticholinergics availalble in South Africa

27. Propiverine Detrunorm® Dose 15 mg 1–3 times daily to 15 mg 4 times daily Darifenacin Enablex® Dose 7.5 or 15mg per day Solifenacin Vesicare® Dose 5 or 10mg per day Anticholinergics availalble in South Africa

28. Persistence on Specific Medications for OAB Based on Prescription Data Chui M, et al. Value in Health. 2004;7:366. Percent Months

29. 100% Why do patients stop taking antimuscarinic therapy? 2 18 9 14 10 13 57 47 50 58 61 66 30 39 24 31 30 26 24 16 4 3 7 4 2 3 2 9 8 0%10%20%30%40%50%60%70%80%90% Insufficient efficacy Intolerable side effects Dosing convenience Other reasons Female ≤55 Years of Age Female >55 Years of Age Male In Employment/Activity Working Retired/Unemployment OAB Dry Pure UUI Mixed UI Reference: Global Market Research Study (Yamanouchi Pharma Ltd, December 2003:n=736). International web survey

30. Options?? When Anticholinergics Fail

31. Botulinum Toxin

32. Administration

33. 12 weekly sessions of 30mins Success expected after 6-8 session Tapering protocol – once every 2-3 weeks PTNS Posterior Tibial Nerve Stimulation

35. When to refer Mixed incontinence with obvious stress component High residual Failure to respond to anticholinergics Haematuria Painful bladder

36. Managing Stress Incontinence

37. Colposuspension

38. Tension free vaginal Tape (TVT)

41. Retropubic Tape

43. Pubic Symphysis TVT Needle Bowel Anterior Abdominal Wall

45. Transobturator Tape

47. Continence rates Both between 85 and 90%

48. Complications Transobturator and Retropubic –Voiding dysfunction –Worsening in Overactive Bladder Retropubic –Bladder / bowel injury –Haematoma Transoburator –Groin pain

49. Bottom line about stress incontinence surgery Relatively good outcomes Refer to a competent surgeon Be aware of complications

50. Recurrent UTI More than 3 UTI in one year

51. Recurrent UTI Causes Genetic Atrophy Foreign body in bladder High urinary residual Prolapse Stroke

52. Recurrent UTI Work up Residual Ultrasound KUB Think about referring for cystoscopy

53. Recurrent UTI Treatment Empty bladder before and after sex Cranberry juice/ tabs Premarin cream Address high urinary residual Daily prophylactic antibiotics