1. Female Urinary Incontinence

2. Pregnancy

3. Urinary Incontinence and Prolapse Incontinence and prolapse commonly coexist But, – they do not always share a common cause – or a common treatment

4. Types of Urinary Incontinence:  Stress incontinence  Urge incontinence  Mixed  Chronic urinary retention and overflow incontinence  Miscellaneous (UTI, dementia, fistulae)

6. NICE Guidelines (October 2006) Woman presents with urinary incontinence Categorise as – Stress incontinence – Urge incontinence/Overactive bladder – Mixed stress and urge Start treatment on that basis

7. NICE Guidelines Initial Assessment (stress, urge, mixed) – Identify factors that need referral – Ask woman to complete a bladder diary for 3 days – Urine dipstick for glucose, protein, leucocytes and nitrites

8. Frequency / Voiding chart Keep chart for 3-7 days Gives an idea of fluid intake Useful in explaining to patient about changes to intake

9. Advice about lifestyle factors High or Low fluid intake (from intake/output fluid charts) Weight loss if BMI > 30

10. Increased Intra-abdominal Pressure:  Pregnancy  Pulmonary disease – smokers cough  Constipation/straining  Lifting – work and home  Exercise  Obesity

11. Stress Incontinence Refer to continence advisor / specialist physio for at least 3 months. (should know by 3-6 months if improvement) If improvement inadequate, refer to secondary care – surgery or duloxitene (Yentreve) (by protocol)

12. Pelvic Floor Exercises

13. Urge incontinence / Over-active bladder Reduce caffeine intake In postmenopausal women prescribe local vaginal estrogen – cream, vaginal tablets, ring Refer to continence advisor for bladder training If ineffective consider oxybutinin or alternatives If ineffective, refer to secondary care for urodynamic investigation / further treatment

14. Drug treatment for urgency/OAB oxybutinin OR – clarifenacin – solifenacin – tolterodine – trospium – different oxybutinin formulations

15. Mixed incontinence Treat whichever symptom predominates (what is your worst problem?)

16. Urgent referrals (2 week wait) Microscopic haematuria in women aged 50 and over - urology Vsible haematuria – urology Recurrent or persisting UTI associated with haematuria in women aged 40 and older – urology Sspected malignant mass arising from urinary/genital tract – urology or gynaecology

17. Indications for referral Symptomatic prolapse that is visible at or below the vaginal introitus – gynaecology The finding of a palpable bladder on bimanual or abdominal examination after voiding – urology or gynaecology

18. Consideration for referral Persisting bladder or urethral pain – urology or gynaecology Clinically benign pelvic masses – gynaecology Associated faecal incontinence – gynaecology/colorectal Suspected neurological disease – neurology, urology, gynaecology Symptoms of voiding difficulty – urology or gynaecology

19. Consideration for referral Suspected urogenital fistulae – urology or gynaecology Previous continence surgery – gynaecology or urology Previous pelvic cancer surgery – gynaecology or urology Previous pelvic irradiation – gynaecology or urology

20. Conditions requiring referral to secondary care or specialist unit Uncertain diagnosis, no clear treatment plan Unsuccessful treatment Patient requests further treatment Surgery contemplated or previous surgery failed Haematuria without infection Symptomatic prolapse

21. Surgery:  For stress incontinence  Tension-free vaginal tape – TVT  Burch coplosuspension  Anterior colporraphy, anterior repair  Bladder neck injections – Zuidex  For overactive bladder  Bladder distension, urethral dilatation  Botox injections to bladder wall  (Detrusor myectomy, clam enterocystoplasty)

22. Surgical treatment for incontinence Discussion – Benefits Success rate Associated improvements Quality of life – Risks Surgical Development of overactive bladder Quality of Life

23. Surgical treatment for incontinence - operations Tension-free Vaginal Tape (TVT) – Relatively simple technique – Inserted under local anaesthetic – Day Case – Quick return to work – about 2 weeks Good initial success both as primary and secondary procedure Long-term success figures – up to 11 years

24. TVT – tension free vaginal tape

25. TOT - Transobturator Tape

26. Prolapse

27. 4 options Do nothing – if asymptomatic Physiotherapy – if minor (stage 1) Vaginal support pessaries – suit some Surgery – Traditional vaginal repair – Newer meshes

28. Menopause and HRT

29. HRT, where are we now? Up to 2002 – Widespread HRT use 2002 Women’s Health Initiative Study Million Women Study CSM advice 2002 - present Further reanalysis since – still ongoing HRT use fallen by 50% but now used more appropriately

30. Observational Studies of HRT Reduction in symptoms (flushes, sweats, emotional, vaginal dryness) Reduction in risk of Coronary Heart Disease Reduction in osteoporotic fractures Increase in risk of thrombosis Increase in risk of breast cancer Reduction in risk of colo-rectal cancer

31. WOMENS HEALTH INITIATIVE RCT Designed to – last for 8.5 years – look at major health benefits and risks associated with the most commonly used HRT in the US i.e. CEE +/- MPA against placebo JAMA 2002; 288: 321-33

32. Risk of Hip fracture – effects of E+P vs E alone E+P E alone

33. Risk of invasive breast cancer – effects of E+P vs E alone E alone E+P

34. Risk of Coloectal cancer – effects of E+P vs E alone E alone E+P

35. Risk of coronary heart disease – effects of E+P vs E alone E alone E+P

36. Risk of Stroke – effects of E+P vs E alone E alone E+P

37. Hazard ratios from WHI trialsClinicalEventWHIE+P WHI E alone CHD 1.29 (1.02-1.63) (1.02-1.63)0.91(0.75-1.12) Stroke1.41(1.07-1.85)1.39 (1.10-1.77) (1.10-1.77) PE2.13 (1.39-3.25) (1.39-3.25)1.34(0.87-2.06) Breast cancer 1.26(1.00-1.59)0.77(0.59-1.01) Colon cancer 0.63(0.43-0.92)1.08(0.75-1.55) Hip fracture 0.66 (0.45-0.98) (0.45-0.98)0.61(0.41-0.91) Death0.98 (0.82-1.18) (0.82-1.18)1.04(0.88-1.22) Global index 1.15(1.03-1.28)1.01 (0.91-1.12) (0.91-1.12) Risk Possible risk/benefit Benefit

38. CSM advice for HRT December 2002 Benefits of short term HRT outweigh risks (up to 2-3 years) If using long term HRT for symptoms, discuss with doctor on a regular basis (at least once a year) Do not use HRT simply to prevent cardiovascular disease December 2003 Do not use HRT as first line treatment for osteoporosis unless other indications – ‘symptoms’ Current Use HRT at minimum effective dose for shortest duration i.e. use HRT for as long as necessary to achieve the objectives of treatment (symptom relief), but keep dose to a minimum

39. What do we tell patients now?

40. What does HRT do to your risk of developing certain diseases? Reduction in symptoms (flushes, sweats) Reduction in osteoporotic (hip) fractures Increase in risk of thrombosis (blood clots) with oral HRT (but probably not with non-oral preparations) Increase in risk of breast cancer with combined HRT (but probably not with estrogen only HRT) Reduction in risk of bowel cancer with combined HRT Increase in stroke and heart attacks in elderly patients, probably on starting any HRT

41. Regimens of HRT Oestrogen only - systemic Combined sequential E + P Continuous combined E + P Tibolone (Livial) Long cycle E + P (3 monthly) Estrogen with MIRENA IUS Local estrogen – tablets, creams, pessaries

42. Who needs HRT? Premature ovarian failure (early menopause) – No randomised data but observational data suggest good protection – HRT or the pill are helpful – Risks of breast cancer - by 50, risk is the same as if had periods to 50 i.e. it is the lifetime duration of exposure to oestrogen and progestogen which is important

43. Who needs HRT? Symptomatic women Very few contraindications to HRT – Estrogen dependent cancer – Current or high risk of thrombosis (use non-oral) – High risk of cardiovascular disease (?use non-oral) Side effects will occasionally restrict use

44. How long should a woman take HRT for?

45. Duration of HRT It depends on the indication(s) for HRT Premature menopause Continue at least until age 51 May need much higher doses at a young age Symptoms flushes – 80% ended at 5 years vaginal dryness continues for life but may cease to be a problem The body responds to lower doses of HRT as the woman gets older

46. Duration of HRT Breast cancer – Clear duration dependent increased risk with E+P, commences after the first 4 years of treatment – Overall mortality may not be increased – Possibly no increased risk with E only HRT – Risks vary with Family history Personal history of premalignant changes

47. Duration of HRT INDIVIDUALISE – A good policy is to review risks vs benefits at 2 years and annually after that – Allow patients to be guided by ‘quality of life issues’ – if coming off HRT causes a poor quality of life, discuss risks vs benefits (for them) – restart if they wish – Aim for lowest effective dose

48. Stopping HRT For women who have been on HRT for >1 year, best to reduce dose gradually. If initial indication was not for symptom relief, may stop treatment abruptly.

49. Ten tips to treating the menopause 1) Counselling for HRT - risks Breast cancer Related to duration of treatment Probably no increased risk with estrogen only HRT ThrombosisRisk 2-3 / 10,000 per year Risk greatly with patch/gel (non oral) StrokeRisk for older age group/hypertensive Dose related CV diseaseRisk in older patients commencing HRT

50. Ten tips to treating the menopause 2) Counselling for HRT benefits Menopausal symptoms relieved Quality of life improvements Osteoporosis/fractures reduced Bowel cancer, reduced risk (E+P treatment)

51. Ten tips to treating the menopause 3) Take care with Hormone dependent cancers Previous or high risk of thrombosis (non-oral) High risk CV disease Abnormal bleeding

52. Ten tips to treating the menopause 4) If she’s had a hysterectomy – its easy – Treat with estrogen only HRT – Titrate dose against symptoms – Benefits >> risks generally – No increased risk breast cancer (WHI study) – No decreased risk bowel cancer

53. Ten tips to treating the menopause 4) If she’s had a hysterectomy – its easy – Treat with estrogen only HRT – Titrate dose against symptoms – Benefits >> risks generally – No increased risk breast cancer (WHI study) – No decreased risk bowel cancer

54. Ten tips to treating the menopause 5) Starting HRT If still menstruating, give sequential HRT If stopped menstruating, give continuous combined HRT Titrate dose Older women need a lower dose, younger women need a higher dose

55. Ten tips to treating the menopause 6) Stopping HRT Don’t put an arbitrary time limit on HRT Aim for lowest effective dose Stop HRT slowly by gradually reducing dose Don’t be worried about restarting if bothersome symptoms return

56. Ten tips to treating the menopause 7) Premature menopause (<45) Benefits > risks in younger women Younger women need a higher dose Treat until 51, and then consider whether to continue COC or HRT in younger women – both effective

57. Ten tips to treating the menopause 8) Mirena and HRT Provides adequate progestogen for HRT, Licensed for 4 years duration Most likely to give bleed free HRT at any age. Titrate dose of estrogen to symptom relief

58. Ten tips to treating the menopause 9) Non- hormonal treatments for menopausal symptoms Behavioural Red clover Black Cohosh SSRI/SNRI/Clonidine Acupuncture/Yoga/exercise Vaginal lubricants – silicone based

59. Ten tips to treating the menopause 10) Local (vaginal) HRT Treat for – Vaginal dryness/soreness – Recurrent UTI’s – Sensory urinary symptoms (frequency, urgency) At recommended doses, (treatment twice weekly), can be continued as long as needed, without checks Aim for lowest effective dose for long term treatment.

60. Questions and Discussion