1. The Diagnosis and Management of Urinary Incontinence
Mr C Dawson MS FRCS
Consultant Urologist
Edith Cavell Hospital, Peterborough
Cromwell Clinic, Huntingdon

2. What this talk is about Why Incontinence is an important problem
How to diagnose and manage most types of incontinence
Case presentations

3. Why Incontinence is important
Major health issue that affects an estimated 10 million women worldwide
Approximately 50% of all nursing home residents, and 15-30% of women over age 65 suffer from incontinence
50% of all women over age 18 years have mild stress incontinence

4. Prevalence of Unstable Bladder
The average PCG (population ~ 100,000) will have over 5,600 people with urinary incontinence.1
One-third of residents in residential homes and two-thirds of residents in nursing homes suffer from urinary incontinence.2
Exact prevalence not known because often concealed by sufferers
A SIFO survey in 1998 found that 20% of women and 19% of men over the age of 40 reported unstable bladder1.
Unstable bladder is a very common condition in adults with the average number of 5,600 patients within a PCO.2
The Continence Foundation carried out a Europe-wide survey in November 1998 of over 16,500 sufferers (Over 2,000 within the UK) 2
The worrying trend shown above is that nearly half of those questioned failed to seek medical help, fearing that there was no treatment for them.1
1 The Continence Foundation, Incontinence a Challenge & an Opportunity for Primary Care
2. DoH Guidelines, Good Practice in continence Services

5. Related health problems
Incontinence is a risk factor for:
falls (26% increased risk) and fractures (34% increased risk)
admission to hospital ( fold risk) or nursing facility (2-3.2-fold risk)
Incontinence can be a risk factor for developing other problems.
The risk of falls increases by 26% and fractures by 34% in patients with urge incontinence as they hurry to reach the toilet.2
Nocturia is probably a further risk factor as people find their way to the toilet during the night.
In the over 65s, incontinence is associated with an increased risk of hospitalisation (30% for women and 50% for men) and an increase in the risk of admission to a nursing facility by 2.0 for women and 3.2 for men.3
In a sample of 9,008 community residents aged over 65, those with urinary incontinence were 70% more likely to be admitted to an institution and 20% more likely to die within 5 years than others who were continent4

6. Relationship to age
Risk of developing incontinence increases with age1
10% age years
20% age years
32% age years
Incontinence can be a risk factor for developing other problems.
The risk of falls increases by 26% and fractures by 34% in patients with urge incontinence as they hurry to reach the toilet.2
Nocturia is probably a further risk factor as people find their way to the toilet during the night.
In the over 65s, incontinence is associated with an increased risk of hospitalisation (30% for women and 50% for men) and an increase in the risk of admission to a nursing facility by 2.0 for women and 3.2 for men.3
In a sample of 9,008 community residents aged over 65, those with urinary incontinence were 70% more likely to be admitted to an institution and 20% more likely to die within 5 years than others who were continent4
1. Sifo Research & Consulting, Pharmacia & Upjohn 1998

7. Prevalence of incontinence by age
Percentage
These data come from a MORI poll of 1883 men and 2124 women aged over 30.2 The questionnaire asked whether respondents had experience of a list of 15 health problems, including backache, chest pain and depression; bladder problems was the third item on this list and was defined as leaking, wet pants or damp pants.
It is clear from this that the prevalence of incontinence increases with age.1
Age
1. Brocklehurst JC. Br Med J 1993;306:832-4
2. MORI Social Research Survey, August 1998

8. The Cost of Unstable Bladder
Diagnostic evaluation (blood tests/urodynamics/urine)
Treatment (e.g. drug therapy/bladder retraining)
Rehabilitation
Incontinence pads/catheters
Secondary consequences, e.g. skin irritation
Admission to residential/nursing home
This slide lists the main categories of direct costs to the NHS for the management of unstable bladder.
It does not take into account the possible impact on productivity of patients, nor the negative effects on their quality of life.
Most of these costs fall within primary care.

9. Estimating the cost to the NHS
This estimate of the total cost of incontinence services to the NHS in England was prepared by the Continence Foundation1.
Note that drug treatment accounts for only 6.4% of total spending.
The estimate does not include the cost of admission to residential, nursing home or long-term hospital care.
This estimate translates to a cost per 1,000 population of £7, or £7 for every person in the country.
*This estimate makes no allowance for overheads beyond direct employment costs e.g. for the appropriate shares of the cost of premises and of ancillary staff
The Continence Foundation. Making the Case for an Integrated Continence Service. 2000

10. Cost of containment products in the U.K. in £M
Costs
Cost of containment products in the U.K. in £M
The cost of containment products has increased substantially since 1996 with estimates for 2001 in the region of £230M.
Euromonitor. World Survey of Incontinence Products Euromonitor. London

11. Impact of Urinary Incontinence on Quality of Life
Distress
Embarrassment
Inconvenience
Threat to self esteem
Loss of personal control
Desire for normalisation
Health is not merely the absence of disease, but complete physical, mental and social well being.
Many studies have identified the impact of incontinence on the quality of life and some key themes emerge.
Distress
Embarrassment
Inconvenience
Threat to self esteem
Loss of personal control
Desire for normalisation
People who are incontinent have a significantly lower health status and significantly great health needs1.
Kobelt G et al BJU International 1999; 83:583-90
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12. Impact of Urinary Incontinence on Quality of Life
Introduction of coping techniques1,2
Avoiding social interaction
Toilet mapping
Carrying spare clothing
Avoiding long travel / journeys
Can lead to social exclusion2
A patient will be forced to use coping mechanisms such as drinking less, toilet mapping and carrying spare clothing to avoid any potential embarrassment as a result of their condition.
This, in turn can lead to restricted employment, education and social opportunities eventually leading to social exclusion.
1. MORI Social Research Survey, August 1998
2. Brocklehurst JC, BMJ Vol

13. Why you need to know about it
Patients often fail to seek help, and must therefore be supported when they do
Prevailing attitude from patients - “nothing can be done”
Many patients with mild symptoms can be greatly helped by simple investigations and treatment

14. How to diagnose and Manage Incontinence
Recognise opportunity for diagnosis
Take a full history
Full examination
Investigations
Management

15. Why screen in Primary Care?
Why screen for patients with unstable bladder?
Prevalence
Cost
Government Initiatives
Good Practice in Continence Services
National Services Framework targets
This slide summarises the key issues why GPs should screen for unstable bladder in primary care.
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16. Opportunities for screening
New Patient medical questionnaires
New Patient medical examinations
Routine cervical smears
Family planning / Menopause clinics
Patient leaflets / posters
Practice audit
Health visitors / District nurses / Practice nurses
Over 75 y.o. checks
Nursing homes
There are many opportunities for the Primary Care Team to screen patients for unstable bladder.
New Patient medical questionnaires
New Patient medical examinations
Routine cervical smears
Family planning / Menopause clinics
Patient leaflets / posters
Practice audit
Health visitors / District nurses / Practice nurses
Over 75 y.o. checks
Nursing homes
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17. Examination in Primary Care
General - look for signs of systemic disease
Weight / BMI
Abdominal examination
Palpable abdominal or pelvic mass / bladder
Pelvic examination
Atrophic changes in vulva / vagina
Utero-vaginal prolapse
Demonstrable incontinence on coughing
Rectal examination
Tone of sphincter, exclude faecal impaction/prostatic
Brief neurological / mental state examination
Examination in primary care should include:
General - look for signs of systemic disease
Weight / BMI
Abdominal examination
Palpable abdominal or pelvic mass
Palpable bladder
Pelvic examination
Atrophic changes in vulva / vagina
Utero-vaginal prolapse
Demonstrable incontinence on coughing
Rectal examination
Tone of sphincter, excludes faecal impaction/prostatic
Brief neurological / mental state examination

18. Diagnosis in Primary Care
Other investigations may be possible in primary care (but are more likely to require referral):
Pad testing
Urodynamics
Measurement of urine flow
Residual volume
Subtracted cystometry
Videocystourethrography (VCU)
Cystoscopy
There are various diagnostic techniques that can be utilised in primary care.
All the above diagnosis techniques are unlikely to be carried out in primary care before referral to secondary care.
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19. The Management of Incontinence
Types of Incontinence
Symptoms and Signs
Investigations
Management

20. Types of Incontinence Anatomic or Genuine urinary stress incontinence
Urge Incontinence
Mixed
False (Overflow) Incontinence
Neuropathic Incontinence
Congenital
Post-traumatic or iatrogenic
Fistula

21. Types of Incontinence Mixed Urge Stress
Treat as detrusor instability (unstable bladder)
(urinalysis & physical examination normal)
Frequency
Urgency
Nocturia
Urge Incontinence
‘Cough & Leak’
Small Volume
Stress and Urge Incontinence
Patients may present with symptoms of unstable bladder, stress incontinence or a mixture of the two conditions.
The diagram above shows that sufferers with pure unstable bladder may have the symptoms of urgency, frequency, nocturia and/or urge incontinence - (described as incontinence proceeded by a strong sudden urge to urinate; the volume of urine lost is often large.)
Those with pure stress incontinence experience incontinence on physical exertion e.g. on laughing, sneezing, coughing or exercising.
Those with mixed incontinence experience both the symptoms of unstable bladder and those of stress incontinence; however, the incontinence can be unpredictable and large volumes can be lost without the proceeding signal of urgency.
Adapted from: P Hilton, SL Stanton, BMJ, Vol 282, 1981

22. Incontinence in males
By contrast with women, the most common of these forms of incontinence in men is urge incontinence. This is probably due to differences in pathologic anatomy and the pathophysiology of incontinence in men.
Hampel et al. Urology 1997; 50 (suppl 6A):4-14

23. Incontinence in females
Incontinence in females is split almost 50:50 between those with genuine stress incontinence and those with urge or mixed symptoms.
Hampel et al. Urology 1997; 50 (suppl 6A):4-14

24. Genuine Stress Incontinence (GSI)
Cause
Symptoms and Signs
Hypermobility of the vesico-urethral junction owing to pelvic floor weakness
Leakage of urine in response to any physical activity - e.g. coughing, sneezing, bending down, exercise

25. Genuine Stress Incontinence (GSI)
Diagnosis
Management
Incontinence may be demonstrable on examination. Urodynamics (VCMG) will confirm
Pads
Weight Loss
Pelvic Floor Exercises
Surgery (Colposuspension, endoscopic bladder neck suspension)

26. Urge Incontinence (UI)
Cause
Symptoms and Signs
Detrusor instability with a normal sphincter, normal anatomy, and no neuropathy
Leakage occurs due to unstable bladder contraction (NB - can be precipitated by cough and therefore mimic GSI)
Usual symptoms of urgency, and frequency with or without urge incontinence

27. Unstable Bladder Symptoms
Frequency is defined as 8 or more voids in 24 hrs.1
Urgency is a sudden, strong desire to void.2
Urge incontinence is a wetting episode preceded by the sensation of urgency.2
Hample C et al, Urol 50 (Suppl 6A) Decenber 1997
Frequency is defined as 8 or more voids in 24 hrs.1 Urgency is a sudden, strong desire to void and urge incontinence is a wetting episode preceded by the sensation of urgency.2
1. Fast Facts - Continence 2000, Shah & Leach
2. Hampel C et al, BJU International (1999), 83, Suppl . 2.,

28. Urge Incontinence (UI)
Diagnosis
Management
History is suggestive. Examination to rule out other factors. Urodynamics (VCMG) will confirm
Lifestyle changes
Anticholinergic medication is first line therapy (NB warn patient about side effects)
Clam Ileocystoplasty

29. Modification of behaviour
Set realistic expectations for the outcome of treatment.
Log improvement in a diary
Bladder retraining:
Re-educating the bladder to hold larger amounts of urine by gradually increasing the time between voids.
Avoid caffeine and alcohol
Reduce fluid intake
Improve mobility and access to toilets
Behaviour modification can be used as an adjunct to pharmacological therapy but it is sometimes used prior to drug therapy. Either way it hinges around the patient and/or carer taking some of the ownership for improving the patient’s condition.
Bladder retraining aims to increase the intervals between voiding and the volume voided. Patients can be encouraged to use a diary to record both parameters so that they have a clear baseline and evidence of progress. Targets should be mutually agreed and support should be provided to attain them.
Fluid intake should be optimised to approximately 2 L/day. Intake of diuretics such as alcohol and caffeine should be reduced or avoided.
Factors affecting access that should be considered for elderly people and those with a disability include: mobility; manual dexterity; grab rails or a rising seat in the toilet; alternatives to a toilet (commode, hand-held urinal); the attitude of carers and the patient; and assessment of possible contributory drug therapy.
Fast Facts, Urinary Continence,2000, Shah & Leach

30. Pharmacological treatment of unstable bladder includes:
Antimuscarinic drugs:
The most widely used in the U.K.
Oxybutynin (Ditropan)
Tolterodine (Detrusitol)
Propiverine (Detrunorm)
Antispasmodic drugs:
Flavoxate
Tricyclic antidepressants
Oestrogens
The aim of drug treatment is to increase bladder capacity by inhibiting detrusor muscle overactivity. For men and women with urge incontinence, antimuscarinic agents are the principal drugs used.
The rationale for antimuscarinic agents is that the predominant stimulus for bladder smooth muscle contraction is the release of acetylcholine from postganglionic parasympathetic nerves innervating smooth muscle cells. Blocking cholinergic activity depresses bladder contractility and involuntary contractions by increasing the bladder volume at which involuntary contractions occur; early bladder contractions are also diminished in amplitude.
Flavoxate is an anti-spasmodic with efficacy comparable to placebo.2
The role of oestrogens as a hormone replacement therapy for women whose symptoms are secondary to oestrogen deficiency.
Tricyclic antidepressants are sometimes used, particularly in the elderly, and in children with nocturnal enuresis. All have significant anti-cholinergic effects and should be used with extreme caution.3
1. British National Formulary No. 41. March 2001
2. Chapple et al, BJU 1990;66,
3. MIMS August 2001

31. Surgery Cystodistension Clam ileocystoplasty
Suspension/sling techniques
Injectable therapy
Surgery is reserved for problems that are unresponsive to other treatments.
Cystodistension and Clam ileocystoplasty are techniques that augment bladder storage capacity in unstable bladder patients.
Cystodistension may temporarily help in minor degrees of bladder instability.
Clam ileocystosplasty provides relief of intractable frequency, urgency and urge incontinence for a high percentage of patients; however, it is a major surgical procedure and runs the risk of post operative voiding dysfunction necessitating intermittent catheterisation1
A 1994 meta-analysis concluded that cure rates for stress incontinence at months for suprapubic bladder neck suspensions and slings were >86% for a first operation and >83% for a second. 2
Injection of periurethral bulking agents or purified collagen implant is relatively quick and straightforward, and is associated with low morbidity, but long-term cure rates are of the order of 40% - 60%. This approach is most suitable for frail elderly women and after multiple failed procedures2.
1. Fast Facts, Urinary Continence, 2000, Shah & Leach
2. Bidmead J, Cardozo L. Lancet 2000;355:2183-4

32. Clam Ileocystoplasty

33. Mixed Incontinence Many women will have both GSI and UI
The management of these conditions is very different
Accurate Assessment is important

34. Aid to Diagnosis

35. Neuropathic Incontinence
Incontinence in the presence of a demonstrable neuropathy
Incontinence can be active (detrusor hyper-reflexia), or passive (atony of sphincter), or a combination of the two

36. Congenital Incontinence
Ectopic ureters
Epispadias
Exstrophy
Cloacal malformation
Specialist Opinion will be required in all cases

37. Overflow Incontinence
Usually the result of obstructive or neuropathic lesion
Commonly seen in men with BPH
Often no preceding symptoms
Examination vital to detect over full bladder
Confirm with portable USS (large +++ residue)
Needs referral to Urologist

38. Traumatic Incontinence
Associated with
Pelvic Fracture
Sphincter damage post-TURP (note this is not GSI as sphincter is intact in GSI)

39. Fistula Can be ureteral, vesical, or urethral
Usually iatrogenic, after pelvic or vaginal surgery
Needs specialist opinion and surgical repair

40. Case Presentations

41. Case 1

42. Case 1 - answer

43. Case 2

44. Case 2 - answer

45. Case 3

46. Case 3 - answer

47. Case 4

48. Case 4 - answer

49. Case 5

50. Case 5 - answer

51. Case 6

52. Case 6 - answer

53. Case 7

54. Case 7 - answer

55. Case 8

56. Case 8 - answer

57. Case 9

58. Case 9 - answer

59. Case 10

60. Case 10 - answer

61. Case 11

62. Case 11 - answer

63. Case 12

64. Case 12 - answer