3ObjectivesDescribe the evaluation of patients with urinary incontinenceDiscuss how to diagnose different types of urinary incontinenceList treatment considerations for different types of urinary incontinenceDescribe when to refer patients with urinary incontinence
4Normal Micturition Cycle Detrusor muscle relaxes as it fills with urine due to sympathetic stimulation. Parasympathetic stimulation causes the bladder to contract and urethral sphincter and pelvic muscle to relax.When urge is strong enough and it is social appropriate to urinate, the pelvic floor relaxes, bladder contracts and you urinate. Bladder is constantly in a state of inhibition to contract. WE consciously release that inhibition, then bladder contracts and you void.
5What is normal? Diurnal frequency- 8 voids Nocturia- 0-1 void Bladder capacity ccNormal voids ccDaily fluid intake ouncesSo what are the normal parameters? These are just general guidelines…400cc bladder capacity is for the best bladder contraction void.Dietician came up with fluid intake of 64 oz daily years ago with no scientific evidence and it has been passed on ever since.
6What is urinary incontinence? Any involuntary loss of urine (International Continence Society/ICS and American Urological Association/AUA)The symptom is the patient’s complaintThe sign is the objective demonstration of urine lossLoss of bladder control (Mayo Clinic)Lots of definitions of UI-some strict, some not.It’s the loss of urine without you wanting it to is the pt’s complaint.The sign is seeing urinary incontinence on exam.At Mayo we commonly say loss of bladder control.
7PrevalenceAt least 50% of patients do not report urinary incontinence 25-51% of the populationAround 13 million in the United States [6,7]More commonly seen caucasians, multiple childbirths , aging , living in a nursing home 
8Types of urinary incontinence StressUrgeMixedOverflowFunctionalNeurogenicTransientLooking at incontinence, the difficulty is addressing the different types.So, it is important to recognize the different types.Stress incontinence most common.Not going to focus much on the functional, neurogenic, transient today-but will give you the definitions so you know.
9Stress IncontinenceInvoluntary loss of urine occurring when the intravesical pressure exceeds the maximum urethral pressure in the absence of a detrusor contraction (ICS)Loss of urine with exertion -coughing, sneezingRisk factors- pregnancy, vaginal deliveries, heredity, obesityNorton’s testWhat is stress incontinence? Losing urine (without wanting to) due to bladder pressures that are higher than urethral/sphincter pressures when the bladder isn’t squeezing. That is the definition from the international continence society.What activities cause this? C, S, running, lifting, reaching, even rolling over in bed
10Urge incontinence (Overactive Bladder) Involuntary loss of urine associated with a strong desire to void/urgency (ICS)Risk factors- aging, obesity, genetics, though usually idiopathic***Urinary tract infectionWhen you get an urge to urinate and can’t make it to the bathroom, that leakage of urine is called urge incontinence.Most common cause of urge incontinence UTI-so rule this out with by taking urine specimen.
11Mixed incontinence Combination of stress AND urinary urge incontinence Mixed incontinence- Those women who are blessed to have both
12Overflow incontinence Bladder is not emptying and overflowsFrequent small urinationsConstant dribblingCauses-Weak detrusor contraction (neurological)Outlet obstruction (pelvic prolapse, surgical procedures)Overflow incontinence is when your bladder is always full/stretched and doesn’t empty.Why does this happen? Your bladder is weak due to a neurogenic cause.Prolapse or surgical procedures can cause outlet obstruction
13Functional incontinence Incontinence due to a physical or cognitive impairment in the setting of a normal functioning urinary tractCauses-Mobility- (arthritis, orthopedic surgery)Cognition- (Alzheimer's disease)Pts using walker after ortho surgery
14Neurogenic Bladders (incontinence) Incontinence due to a neurogenic causeExamples- (multiple sclerosis, spinal cord injuries, parkinsons, stroke)May present as urge, stress, overflow, or retentionRequires a subspecialty appointment with a neurourologist so refer themIf a pt has a neurological diagnosis and bladder symptomatology-she has a neurogenic bladder.
15Transient incontinence Temporary incontinenceOccurs in 33% of community dwelling elderly and 50% of acutely hospitalized patientsSecondary to “DIAPPERS”D eliriumI nfectionA trophic vaginitisP harmacologicalP sychologicalE ndocrineR estricted mobilityS tool impaction [1,2,3]A third of our elderly neighbors have this. ½ of all acutely hospitalized pts do as well.Atrophic Vaginitis-due to a weakened sphincter from weakened vaginal tissueEndocrine-diabetes, diabetes insipidusThe good thing about transient incontinence is that it IS temporary. If you correct the underlying problem, you correct the incontinence.
16Don’t ask, don’t tell-patient perspective Patient embarrassmentBelief that symptoms are normalBelief that symptoms will subsidePatient is unaware of treatment options or that treatment will be successfulAfraid of invasive, costlyprocedures - specifically theCATHETER….Many times the patient is embarrassed.She thinks this is normal.She believes that her incontinence will go away.She doesn’t know something can be done to help her.She is afraid of the deadly catheter or other scary procedures…
17Reasons incontinence is not addressed from a provider perspective Many other important symptoms take precedencePerception that patient is not botheredUnaware of the significant impact on the patient’s quality of lifeUnaware of treatment options or positive benefit of treatmentWhat can be worse than peeing your pants?Don’t be afraid to refer
18Reasons to address incontinence Quality of life improvementMorbidity and MortalityCost
19Quality of LifeQuality of LifePhysicalLimitations or cessationof physical activityPsychologicalGuilt/depressionLoss of self-respect/dignityFearSocialReduction in social activityAlteration of travel plansInstitutionalizationDomesticSpecial precautions with clothingSpecialized underwear, beddingOccupationalAbsence from workDecreased productivitySexualAvoidance of sexualcontact and intimacyThere are many factors affecting quality of life. Physical-limiting activities or even stopping themPsychological- depression, loss of dignitySocial-avoidance of socialization and travelDomestic- changes in clothing (wearing only dark clothes, special underwear, bedding)-hide from partner changing bedsheetsOccupational- absence from work or decreased productivitySexual avoidance
20Morbidity and Mortality InfectionsUTIs, urosepsis, candida, cellulitis, pressure ulcersFalls and fracturesSleep deprivationPsychological ImpactPoor self-esteem, depression, social withdrawal, sexual dysfunctionCaregiver burden [11,13,20]
21CostBillions!$20 billion in 2000 for total urinary incontinence costs to society 56 percent consequence costs (i.e., nursing home admissions) and loss of productivity [15,16]$65.9B in 2007 for OABProjected $76.2B- 2015$82.6B-2020The estimated total national cost of OAB with UUI in 2007 was $65.9 billion, with projected costs of $76.2 billion in 2015 and $82.6 billion in 2020.J Manag Care Pharm Feb;20(2):Economic burden of urgency urinary incontinence in the United States: a systematic review.Coyne KS1,et al (pub med)
22Patient evaluation History Questionnaires Voiding Diary Physical exam Additional testing- urines- post void residual- urodynamics test- cystoscopySo let’s talk about evaluation of our patients. After all it IS one of the objectives of the talk..Can you have the pt call the incontinence helpline shown on this slide? Too bad there’s not one, right?I use the above bullet points with each of my patients.Additional testing is evaluated on a case to case basis.
23HistoryYou may be afraid to ask about the bladder as you could open up a can of worms.Your time is precious and limited with all the medical concerns you need to address.Never be afraid to refer these patients to Urogynecology. I would be happy to personally see them."Whatever you do, just don't get her started on her bladder control problem."
24Patient historyReview Questionnaire (UDI=urogenital distress inventory, IIQ=incontinence impact questionnarie…)OBGYN- number of pregnancies- delivery method (vaginal, cesarean)- instruments used (forceps, suction)- degree of tearing, episiotomyPelvic SurgeryThere are different types of questionnaires. Choose one and be consistent with utilization. We have our own Mayo Urogynecology questionnaire. Some practices use the UDI=Urogenital Distress Inventory. Others use the IIQ or Incontinence Impact Questionnaire. Others create their own questionnaire which we have at Mayo that the patient fills out prior to the appointment or while waiting to be roomed. This helps prepare the patient for what types of questions will be asked and helps them know what they will answer. It has worked well for my patients.
26Bladder diaryThe voiding diary is a nice tool for incontinence evaluation. You can find a lot of answers just by looking at a voiding diary.Fluid intakeUrine outputFrequencyVoided volumes which I have found to be most helpful.Incontinent episodes and descriptions of them –associated with urgency or no urgency AND….. NUMBER OF PADS
27Patient history “Incontinence” When do you leak urine? What triggers your leakage episodes?How often does it happen?Do you wear pads? What kind of pad? How many per day? Are they soaked or damp?When I am talking to a patient about urinary incontinence I ask these questions.Do you wear pads lets us know how bad of a problem the incontinence is.I counsel my patients on using incontinence pads rather than maxi pads to reduce skin irritation and help with holding capacity.
28Patient history Vaginal symptoms Itching, dryness, burning, discharge, bleeding, infection, history of skin conditions such as atrophic vaginitis or lichen sclerosusCan be seen with pelvic prolapse and/or Incontinence
29Patient history Sexual history Sexually active or not Dyspareunia Penetration, movement, orgasm, anorgasmicVaginal dryness-lubricants usedPost coital bleeding?sexually transmitted infectionAbuseIs the patient sexually active?Does she have dyspareunia? If so with what?
30Patient history Bowel symptoms Constipation Fecal incontinence SplintingIncomplete emptyingThe bowels play a large role in bladder symptomatology, which is why I ask about them.I work closely with the Motility clinic as the bowel and bladder go hand in hand.When bowels are not well controlled, neither are bladder symptoms.
31Patient history Neurological Pulmonary Medical Diagnosis Physical MobilityMental Status including psychiatric historyObesityMedical diagnosis-diabetes or diabetes inspidiusSince I brought up obesity-let’s talk about that more as it can negatively affect urinary incontinence.
32Patient history Medication review-diuretics, lithium, etc.. Social Smoking, alcohol, recreational drugsFamily history Gynecological, urological, colorectal malignancy
33Physical ExamGeneralAbdominal /Back(scars, masses, CVA tenderness on the back)Urologic/gynecologicVisual inspectionSkin conditions, rashes, atrophy, vaginal dischargePerineal sensation, reflexes (soft touch/sharp)Cough stress testKegels or pelvic floor myalgiaProlapseMasses-(bartholins, urethral, skenes, diverticulum, bimanual, rectal exam included in this evaluation)
34KegelsSqueezing and releasing the pelvic floor muscles which includes the vagina, urethra, rectum.Same muscle used to stop the urinary stream.Graded as absent, weak, moderate, strong.Can be taught through pelvic floor physical therapy.Used as a treatment option for urinary incontinence.
35Squirting Sue40 yo c/o urinary incontinence only with running (no other urogynecological symptoms)G4, P4 (vaginal, forceps with first 2, 3rd degree tearing with 3rd, largest birth weight 10 lbs)BMI 22PMH/PSH-Healthy. No surgeries.Medications/allergies-None.Bladder diary, urines, post void residual-normalPhysical exam is normal with strong kegels.
36Squirting Sue What is her diagnosis? Transient incontinence Overflow incontinenceUrge incontinenceStress incontinenceMixed incontinence
38Squirting Sue First LineTreatment 1) Urethral insert (Femsoft)2) Pessary3) Kegels on her own4) Pelvic floor physical therapy/biofeedback5) Surgery6) Tell her to wear a pad
39All are potential options, depending on how aggressive the patient wants to be with treatment
40Squirting Sue First LineTreatment 1) Urethral insert (Femsoft)2) Pessary3) Kegels on her own4) Pelvic floor physical therapy/biofeedback5) Surgery6) Tell her to wear a pad
411) Urethral insert (Femsoft) Answer1) Urethral insert (Femsoft)DO NOT USE in pts with urinary tract infections or taking anticoagulants!
42Urgency Ursula70 yo c/o urinary incontinence with a strong urge, urgency, frequency. No incontinence with cough or stress manuevers.G0.PMH/PSH-Healthy. No surgeries. BMI 30.Medications/allergies-None.Labs-Urines and post void residual are normal.She has never been pregnant.Her past medical and surgical history are unremarkable, though she is overweight.No medications or allergies.Labs and post void residual are normal.
43Urgency Ursula’s Physical Exam This is what her vaginal mucosa looks like this
44Urgency Ursula’s Physical Exam This is what Ursula’s external genitalia looks like this.
45Urgency Ursula’s Physical Exam No prolapse or incontinence.Weak kegels.Otherwise, unremarkable.Her physical exam otherwise shows no prolapse or incontinence. She DOES have a weak pelvic floor.So ……. what can we look at next? (Pause)How about her voiding diary?
46Bladder diaryThis is Urgency Ursula’s bladder diary. Let‘s start by looking at the left which is the intake column.We see that she takes in a total of 48 ounces. Is that a normal daily fluid intake??? No, she should have around 60 oz daily for her age (60 and over I usually use). This is just a general guideline. This varies depending on the health and activity status of my patients of course.I also look at what types of fluids my patients take in. Is it generally water? Not in Ursula’s case. She only has 6 oz of water out of the 48 oz total.
47Bladder diaryNext I look at the output column. I look at her total output of 51 oz which coordinates nicely with he input of 48 oz, so there is no concern there.More importantly, though, I look at her individual voided volumes and her frequency. Are these normal voided volumes? Pause. No, they are not. 10oz voids would be normal.So we know so far that Ursula doesn’t drink enough daily fluid. She doesn’t drink enough water and instead takes in dietary irritants which we will discuss in an upcoming slide, and her voided volumes are small capacity voids.You probably are already formulating a diagnosis based on this information. Smile
48Bladder diaryIt is helpful to know how much time the patient has between voids. I say if the patient is voiding every 2 hours during the day, this is normal provided she is taking in a normal fluid intake.
49Bladder diaryI then focus my attention to the right hand column which describes the patient’s urinary incontinence.I look at the frequency of the incontinence, how much she is leaking, what activities provoke it if any, if there’s urgency before she leaks and..How many pads she wears during the day AND night.
50Urgency Ursula What is her diagnosis? 1) Stress incontinence 2) Urge incontinence3) Mixed incontinence and atrophic vaginitis4) Overflow incontinence5) Urge incontinence and atrophic vaginitis
515) Urge incontinence and atrophic vaginitis Urgency Ursula Answer1) Stress incontinence2) Urge incontinence3) Mixed incontinence and atrophic vaginitis4) Overflow incontinence5) Urge incontinence and atrophic vaginitis
52Urgency Ursula Treatment 1) Pelvic floor physical therapy2) Vaginal estrogen3) Dietary irritant avoidance4) Weight loss5) All of the aboveHow will we treat Ursula?
53Urgency Ursula’s Treatment Answer 1) Pelvic floor physical therapy2) Vaginal estrogen3) Dietary irritant avoidance4) Weight loss5) All of the aboveThe answer is number 5-all of the above
54Treatment Overactive Bladder BehavioralModificationFluidmanagementAvoid BladderIrritantsPelvic FloorMuscleStrengthening(Consider PT)UrgeSuppression/AwarenessOf TriggersBladderRetraining/TimedVoidingImproveMobility andCoexistingHealth IssuesBowelHabits/RegularitySince Ursula had an overactive bladder-let’s look at this chart that shows various treatments of OAB. You can see there are many.Behavioral modification plays a big role in improving overactive bladders. In my department, we have special folders with a lot of helpful information that not only we review as providers, but have our urogynecology nurses re-enforce the teaching.
55What are dietary irritants? The 6 C’sCaffeineCitrusCarbonationVitamin CAlcohol (Cocktails)Cigarettes
56Urgency Ursula returns 3 months later Overactive bladder symptoms are no better.She has faithfully followed all recommendations.Vaginal tissue – improvedNormal BMI.4 sessions PT completed.Moderate kegel.Bladder diary-same except for no longer taking in dietary irritants.Unfortunately, Ursula’s symptoms are the same despite following our recommendations.She has estrogenized her vaginal tissue, lost weight, completing pelvic floor physical therapy, and avoided the 6 C’s.
57Urgency Ursula’s return treatment? 1) Anticholinergics2) Surgery3) Continue with conservative therapy as the treatment risks outweigh the benefits4) PessaryExplain why to not use pessary with atrophic tissue and wont’ work for urgencySurgery is not recommended for urgency until you fail medications
58Urgency Ursula’s return treatment answer 1) Anticholinergics2) Surgery3) Continue with conservative therapy as the above treatments risks outweigh the benefits4) PessaryI would start her on medication. Even with her age, it is fine to use. And continue with # 3
59Distribution of Muscarinic Receptors in Target Organs of the Parasympathetic Nervous System Iris/Ciliary Body = Blurred VisionCNSLacrimal Gland = Dry EyesSalivary Glands = Dry MouthDizzinessSomnolenceImpaired Memory & CognitionHeart = TachycardiaGall BladderStomach = DyspepsiaThis slides shows the distribution of muscarinic receptors and is important because by remembering this distribution you can easily recall most of the common SE associated with this class of agents.Muscarinic receptors in the brain are associated in memory deficits and somnolenceLacrimal glands: Blurred visionSalivary glands: Dry mouth (the most common SE with this class of drugs)Heart: Receptors in the SA can cause increase in baseline HR and prolongation of the QT intervalGI tract: constipation: the second most common SEPresence in the bladder accounts for the therapeutic benefit of this class of drugs.Colon = ConstipationBladder (detrusor muscle)Abrams P, Wein AJ. (1998). The Overactive Bladder: A Widespread and Treatable Condition. Erik Sparre Medical AB.
60Available anticholinergics Oxybutynintablet (Ditropan IR, ER)transdermal patch (Oxytrol)-which is OTCtransdermal gel (Gelnique)Tolterodine tartrate (Detrol, IR, ER)Trospium chloride (Sanctura, IR, XR)Fesoterodine fumarate (Toviaz)Darifenacin (Enablex)Solifenacin succinate (Vesicare)Mirabegron (Myrbetriq)7 different anticholinergics available on the marketMyrebetriq is the newest one-only FDA approved Beta 3 adrenergic agonist. Comes in 25 and 50mg tablets. Most common SE was HTN at 11% in trials.
61Which one to chose? In general, you could start with any one. OBJECT trial, Mayo Clinic Proceedings, 2001Oxybutynin ER/ Ditropan XL 10mg dailyGood efficacy, reasonable costIf not effective or side effectsTry another
62Frequent Francis50 yo G0 c/o urinary frequency. Failed Tolterodine tartrate (Detrol LA), Fesoterodine fumarate (Toviaz), and Solifenacin succinate (Vesicare). Not interested in trying another medication. No dietary irritants.BMI 23.PMH/PSH- healthy.No meds/allergies.Labs-urines normal.Exam-normal with strong kegels.Add a slide for a bladder diary
66Frequent Francis’s Treatment 1) Oxybutynin ER 10mg daily2) Botox3) Sacral Nerve Stimulator4) Augmentation Cystoplasty5) ReferThis really affects franscis . She is at her wits end, so surgery may truly improve her quality of life. She is willing to even do major surgery she tells you.
68Botulinum Toxin Many uses in the medical field today Outpatient surgery injected cystoscopicallyEffective within 2 weeksEffective for 6-12 monthsAround 80% successSmall chance of urinary retention$$$$ so we always ask pt to get insurance pre- approval
69Treatment Urinary Urge Incontinence Surgical Options:Sacral Neuromodulation (Interstim)Uses a small device (battery) which sends electrical impulses through a lead positioned close to S3 sacral nerveModulates the nervous signals to the bladderTENS unit, percutaneous posterior tibial nerve stimulation, interstim
70Wet Wanda57 yo c/o urinary incontinence with urgency (larger volume leakage) and stress activities (small drops). She has constipation. No other complaints.G2, P2 (forceps with first, largest birth weight 9lbs). BMI 28PMH/PSH- Hysterectomy, DM2, HTNMedications- Estradiol TD (Vivelle Dot), Metformin, HCTZAllergies-NKDASH: Drinks 1 pot of coffee daily and has 3 sodas. Smokes 1 pack of cigarettes daily x 25 years.Urines and post void residual are normal.Wanda is 57.She leaks urine with an urgency beforehand as well as when she coughs, sneezes, or does activity.She’s had 2 vaginal deliveries. Forceps assisted her first one who weighed 9lbs.She is overweight.She loves coffee and drinks 1 pot per day. She has 3 daily sodas and is a smoker.There is no urinary tract infection and she empties her bladder well.
71Wet WandaPhysical exam- Normal external genitalia. Normal vaginal mucosa. Weak kegels. No prolapse. With cough, leaks small amount. While getting off the exam table, she had a strong urge and gushed a larger amount of urine.
72Wet Wanda’s diagnosis 1) Stress incontinence 2) Urge incontinence 3) Mixed incontinence4) Overflow incontinenceWhat is her diagnosis?Remember she leaked all over the exam table.
74How do you treat mixed incontinence? Do you treat the stress or urge first?Ask the patient what bothers her mostTreat the most bothersome symptom firstFor Wet Wanda, she is most bothered by her urinary urge incontinenceSo then how would we treat her if she has both?
75Wet Wanda’s first treatment 1) Take her off the HCTZ and do a sling surgery2) Pessary3) Anticholinergics4) Conservative management- avoid constipation, lose weight, avoid dietary/social irritants-smoking, soda, coffee..5) Who knows?So would you..
76Wet Wanda’s answer1) Take her off the HCTZ and do a sling surgery2) Pessary3) Anticholinergics4) Conservative management- avoid constipation, lose weight, avoid dietary/social irritants-smoking, soda, coffee..5) Who knows?.Let’s look at each of these options carefully and discuss them.She leaked urine on exam physical exam, but I wouldn’t jump right to a sling. I also don’t discontinue medications that I haven’t prescribed.She had no prolapse, so I wouldn’t use a pessary. She DOES have stress incontinence, but also urge and I have not seen pessaries help with urge incontinence.Anticholinergics are an option for this patient, but..its always best to start conservatively.4 is the best answer. Referral to a nutritionist. Miralax for her constipation. Behavioral therapy through my urogyn nurses for dietary irritant avoidance and smoking cessation clinic here at Mayo.
78Does weight loss help incontinence? Program to Reduce Incontinence by Diet and Exercise (PRIDE)January New England Journal of Medicine338 women30 and older with a BMI of 25-50greater than 3 months incontinence leaking at least 10 times/week6 month weight loss program and followed for 18 months [18,19]Has anyone heard of the PRIDE study?The PRIDE study stands for Program to Reduce Incontinence by Diet and Exercise.The New England Journal of Medicine was first to publish this in Jan. 2009, September Journal of Urology, August Obstetrics & GynecologyThis was a really neat and helpful study for urinary incontinent patients.
79PRIDE, continued..Group 1-”intensive” weight loss group had diet, exercise, behavioral modification with coaches, classes, etc.. And a follow up 12 month weight maintenance programGroup 2-received information on diet and exercise with NO direct training to help them change habits [18,19]
80PRIDE, continued…Group 1- Lost an average of 8% (about 17lbs) of their body weightInvestigators reported a 47% mean reduction of weekly incontinent episodesGroup 2- Lost an average of 1.6% (about 3lbs) of their body weightInvestigators reported a 28% mean reduction in weekly incontinent episodes 
81Wet Wanda returns 3 months later… She is 50% improved from her urge incontinence, has stopped smoking, lost weight to now a normal BMI, no more constipation.She is interested in more aggressive treatment options.She’s improved by 50% and is happy about that, but would like to be dry.
82Wet Wanda returns 3 months later… Treatment options..1) Haven’t we fixed her yet? She’s still leaking?2) Anticholinergics3) Pessary4) Surgery
83Wet Wanda returns 3 months later… Treatment options..1) Haven’t we fixed her yet? She’s still leaking?2) Anticholinergics3) Pessary4) Surgery
84Wet Wanda returns 2 months later.. Good news!You fixed Wanda’s urge incontinence! It is gone!She has now joined a Crossfit class and has had to stop it due to her bothersome incontinence with these Crossfit exercises.She has been so pleased with your care of fixing her urge incontinence, that she is confident in your ability to fix her stress urinary incontinence.
85Wet Wanda’s treatment for stress incontinence 1) Urethral insert (Femsoft)2) Pessary3) Surgery
86Answer Any option is reasonable. I would present all options to the patient and let her decide as there is no wrong answer.
87Treatment Stress Urinary Incontinence Ring with a Knob PessaryMarland Pessary
88Pessary care Patient self maintenance preferred Removed twice weekly to clean with soap/waterSome use only with activityInserted with a water based lubricantRemoved before intercourseLast usually around 10 yearsAround $80 each
89Leaking Liz37 yo G2, P2 (NSVD) female who leaks with plyometrics which incorporates a lot of jumping.Femsoft worked for her intermittent incontinence (early 20s).Continent pessary worked well from 36-37yo.Now interested in a more permanent fix.Healthy. Normal BMI. No meds/allergies. Unremarkable PMH/PSH. Normal exam with strong kegels.
91Leaking Liz treatments 1) Bulking agent2) Slings***Pt to talk with surgeon to decide correct procedure for her. One size does not fit all.Recovery time versus anesthesia time
92Surgical treatment for stress incontinence Outpatient surgeryBulking agentsPeriurethral injection of material (collagen, macroplastique, etc..) to increase tissue bulk.SlingsPiece of material (like a hammock) inserted transvaginally supporting the urethra.Goal is to reduce stress incontinence without causing obstructive voiding symptoms or urinary retention.
93References1. Resnick NM, Yalla SV: Geriatric incontinence and voiding dysfunction. In: Campbell-Walsh Urology (9th Edition). Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (Eds). Saunders Elsevier, PA, USA, 2305– 2321 (2005).2. Herzog AR, Fultz NH: Prevalence and incidence of urinary incontinence in community-dwelling populations. J. Am. Geriatr. Soc. 38(3), 273–281 (1990).3. Resnick NM: Urinary incontinence in the elderly. Med. Grand Rounds 3, 281–290 (1984). •• Original article suggesting 'delirium, infection, atrophy, pharmaceuticals, excess urine output, restricted mobility, stool impaction' (DIAPERS) mnemonic for transient causes of urinary incontinence in the elderly.4. Matthews CA, Whitehead WE, Townsend MK, Grodstein F: Risk factors for urinary, fecal, or dual incontinence in the Nurses' Health Study. Obstet Gynecol. 2013;122(3):539.5. Branch LG, Walker LA, Wetle TT, DuBeau CE, Resnick NM: Urinary incontinence knowledge among community-dwelling people 65 years of age and older. J Am Geriatr Soc. 1994;42(12):1257.6. Buckley BS, Lapitan MC: Epidemiology Committee of the Fourth International Consultation on Incontinence, Paris, 2008: Prevalence of urinary incontinence in men, women, and children--current evidence: findings of the Fourth International Consultation on Incontinence. Urology. 2010;76(2):265.7. Markland AD, Richter HE, Fwu CW, Eggers P, Kusek JW: Prevalence and trends of urinary incontinence in adults in the United States, 2001 to J Urol. 2011;186(2):589.
94References continued8. Nygaard I, et. al. Pelvic Floor Disorders Network: Prevalence of symptomatic pelvic floor disorders in US women. JAMA. 2008;300(11):1311.9. Offermans MP et al. Prevalence of urinary incontinence and associated risk factors in nursing home residents: a systematic review. Neurourol Urodyn 2009; 28:288.10. Burgio KL, Zyczynski H, Locher JL, et al. Urinary incontinence in the 12-month postpartum period. Obstet Gynecol 2003; 102:1291.11. Brown JS, Vittinghoff E, Wyman JF, et al. Urinary incontinence: does it increase risk for falls and fractures? Study of Osteoporotic Fractures Research Group. J Am Geriatr Soc 2000; 48:721.12. DuBeau CE, Kuchel GA, Johnson T, et al.. Incontinence in the frail elderly. In: Incontinence, 4th ed., Abrams P, Cardozo L, Khoury S, Wein A. (Eds), Health Publications Ltd, Paris p.961.13. Herzog AR, Diokno AC, Brown MB, et al. Urinary incontinence as a risk factor for mortality. J Am Geriatr Soc 1994; 42:26414. Hu TW, Wagner TH, Bentkover JD, et al. Costs of urinary incontinence and overactive bladder in the United States: a comparative study. Urology 2004; 63:461.15. Stothers L, Thom D, Calhoun E. Urologic diseases in America project: urinary incontinence in males-- demographics and economic burden. J Urol 2005; 173:1302.16. Thom DH, Nygaard IE, Calhoun EA. Urologic diseases in America project: urinary incontinence in women- national trends in hospitalizations, office visits, treatment and economic impact. J Urol 2005; 173:1295.
95References continued..17. Coyne KS1, Economic burden of urgency urinary incontinence in the United States: a systematic review. J Manag Care Pharm Feb;20(2):18. Subak LL, et. al. Weight loss to treat urinary incontinence in overweight and obese women. N Engl J Med Jan 29;360(5):19. Wing RR, et. Al. Effect of weight loss on urinary incontinence in overweight and obese women:results at 12 and 18 months. Journal of Urology 2010 Sept;18(3):20. Wing RR., et. Al. Improving urinary incontinence in overweight and obese women through modest weight loss. Obstetrics & Gynecology 2010 Aug;116(2 Pt 1):284-9221. Coyne KS, Sexton CC, Irwin DE, et al. The impact of overactive bladder, incontinence and other lower urinary tract symptoms on quality of life, work productivity, sexuality and emotional well-being in men and women: results from the EPIC study. BJU Int 2008; 101:1388.22.