1. Management of Urinary Incontinence

2. Depends on the patient! Age Effect on quality of life
Type of incontinence
Presence of prolapse

3. Activity!
Sort the cards into management options for stress incontinence or overactive bladder.
Line them up in the order that you would offer them, there may be more than one at the same time.
Of course, not every option is suitable for every patient.

4. Stress incontinence Conservative Medical Surgical
Lifestyle interventions
Vaginal oestrogen
TVT
Pelvic floor repair
Pelvic floor exercises +/- biofeedback
Duloxetine
Vaginal cones
Ring pessary

5. Overactive Bladder Conservative Medical Surgical
Lifestyle interventions
Vaginal oestrogen
Sacral nerve root stimulation
Bladder retraining
Anti-muscarinics
Botox
Pelvic floor exercises
Detrusor myomectomy
Augmentation cystoplasty

6. Lifestyle Interventions

7. Pelvic Floor Exercises
More effective if supervised
+/- biofeedback
Refer to community continence services
Vaginal cones

8. Bladder Retraining To re-establish cortical control over voiding
Regular voiding, gradually increasing intervals.
Using distraction and relaxation techniques
Bladder diary will show improvement

9. Ring Pessary Anterior prolapse predisposes to stress incontinence
Changed every 4-6 months
Conservative option

10. Anti-muscarinic medication
Oxybutinin 2.5mg, 5mg
Tolterodine (Detrusitol), Trospium (Regurin)
CI: myasthenia gravis, significant bladder outflow obstruction or urinary retention, severe ulcerative colitis, toxic megacolon, and in gastro-intestinal obstruction or intestinal atony.
SE: dry mouth, gastro-intestinal disturbances including constipation, flatulence, taste disturbances, blurred vision, dry eyes, drowsiness, dizziness, fatigue, difficulty in micturition (less commonly urinary retention)
Try several before giving up

11. Other medications
Duloxetine SNRI Increases urethral closure pressure 20-40mg bd SE: GI disturbance, headache, dry mouth, rarely suicidal ideation Vaginal Oestrogens e.g. Ovestin, Vagifem, Ortho-gynest All postmenopausal women not on HRT Oestrogen breaks advised (?endometrial Ca risk)

12. Surgery for Stress Incontinence
Tension-free Vaginal tape (TVT)
Pelvic Floor Repair

13. Surgery for Overactive Bladder
A last resort!
Sacral nerve root stimulation
Botox
Detrusor Myomectomy
Augmentation Cystoplasty

14. Any Questions?