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

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Presentation on theme: "The Diagnosis and Management of Urinary Incontinence Mr C Dawson MS FRCS Consultant Urologist Edith Cavell Hospital, Peterborough Cromwell Clinic, Huntingdon."— Presentation transcript:

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 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 (1.3-1.5-fold risk) or nursing facility (2-3.2-fold risk)

6 Relationship to age Risk of developing incontinence increases with age 1 –10% age 45-49 years –20% age 60-64 years –32% age 70-74 years 1. Sifo Research & Consulting, Pharmacia & Upjohn 1998

7 Prevalence of incontinence by age 1. Brocklehurst JC. Br Med J 1993;306:832-4 2. MORI Social Research Survey, August 1998 Percentage Age

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

9 Estimating the cost to the NHS *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 Costs 1992 - 2001 Euromonitor. World Survey of Incontinence Products 1997. Euromonitor. London Cost of containment products in the U.K. in £M

11 Impact of Urinary Incontinence on Quality of Life Distress Embarrassment Inconvenience Threat to self esteem Loss of personal control Desire for normalisation 015 Kobelt G et al BJU International 1999; 83:583-90

12 Impact of Urinary Incontinence on Quality of Life Introduction of coping techniques 1,2 –Avoiding social interaction –Toilet mapping –Carrying spare clothing –Avoiding long travel / journeys Can lead to social exclusion 2 1. MORI Social Research Survey, August 1998 2. Brocklehurst JC, BMJ Vol 306 1993

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 047

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 052

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

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 022

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 Incontinenc e Cough & Leak Small Volume Frequency Nocturia Urgency Stress and Urge Incontinence Adapted from: P Hilton, SL Stanton, BMJ, Vol 282, 1981

22 Incontinence in males Hampel et al. Urology 1997; 50 (suppl 6A):4-14

23 Incontinence in females 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 1. Fast Facts - Continence 2000, Shah & Leach 2. Hampel C et al, BJU International (1999), 83, Suppl. 2., 10-15.

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 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 1. British National Formulary No. 41. March 2001 2. Chapple et al, BJU 1990;66,491-494 3. MIMS August 2001

31 Surgery Cystodistension Clam ileocystoplasty Suspension/sling techniques Injectable therapy 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

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43 Case 2

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45 Case 3

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49 Case 5

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51 Case 6

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