1. Keeping the right patients away from hospital
Richard Foon
Consultant Obstetrician & Gynaecologist
Royal Shrewsbury and Telford NHS Trust

2. Department Consultants Other doctors Continence nurse advisors
Physiotherapists
Urodynamics Team

3. Uro - gynae - cology
Prolapse
Stress incontinence
Overactive bladder

4. Asymptomatic – no treatment needed
Prolapse
Symptomatic
Asymptomatic – no treatment needed
Conservative
Treatment
If stage 1
Pessary
Surgery
If surgery fails
Pessary
Mesh

5. Treatment of Prolapse Reassure (Conservative, PFMT) Ring (Pessaries)
Repair (Surgery)

6. Prolapse staging

7. Definitions
Urinary incontinence (symptom): complaint of involuntary loss of urine
Stress (urinary) incontinence: complaint of involuntary loss of urine on effort or physical exertion (e.g. sporting activities), or on sneezing or coughing
Urgency (urinary) incontinence: complaint of involuntary loss of urine associated with urgency

11. Recommend PFMT and many claim excellent results but does the evidence support this?

12. Stress Incontinence – History, Exam etc
Cured – Up to 50%
Stress Incontinence – History, Exam etc
Physiotherapy
Not cured - Urodynamics
Medical tx
Urodynamic stress incontinence
Macroplastique
Surgery
Tapes

13. Costs (based on 100 patients)
Before Implementation
After
Implementation
PFMT in
Primary Care
£10,000
Treatment in Secondary Care
£81,550
£28,542
Total
£38,542
(LB’s pts not included, those whose letters are seen by other consultants, those who ‘slip thro’ the net)
Savings/Cost Avoidance = £43,008
Personal communication R Freeman 2012

14. UUI Conservative Treatment
Behaviour Modification (Continence advisor)
Bladder Re-training
Fluid management
Pelvic Floor Muscle Training (Physiotherapist)
Better supervised’
Compliance
Anti-muscarinic drugs
Various Preparations

15. Anticholinergic drugs
Oxybutynin
Tolterodine
Trospium chloride
Solifenacin
Fesoterodine
Darifenacin

16. Mirabegron A first in class β3-adrenoceptor agonist1
Mirabegron – A new class of OAB treatment
A first in class β3-adrenoceptor agonist1
Mirabegron works differently to antimuscarinics1,2
The challenge of treating OAB:
By the end of this section, the audience will recognise the need for new therapies that can address the concerns of currently available OAB treatments
Mirabegron - A new class of OAB treatment:
This section will give the audience a better understanding of science behind mirabegron and the potential benefits of a mode of action that differs from antimuscarinic therapy
Gras J. Drugs of Today 2012;48(1):25–32.
Betmiga Summary of Product Characteristics, December 2012.
Date of preparation: February BET13018UK

17. Special warnings and precautions
Use with caution :
autonomic neuropathy
hiatus hernia
clinically significant bladder outflow obstruction
severe constipation
narrow-angle glaucoma;
gastrointestinal obstructive disorders
gastro-oesophageal reflux

18. Voiding dysfunction
Post void residual - > 30 % of functional bladder capacity
Bladder scan- within 1 minute of void
Residual up to 50 mls
Iatrogenic : Radical pelvic surgery/TVT
Pelvic organ prolapse ( 33% stage 3/4)
Urethral strictures

19. Who to refer ? Failed anticholinergics x 2
Unable to take anticholinergics ( eg: closed angle glaucoma)
Suspicion of other pathology ( Pelvic masses , neurological causes, retention)
Haematuria
Some iatrogenic causes

20. Who to refer
microscopic haematuria in women aged 50 years and older visible haematuria
recurrent or persisting UTI associated with haematuria in women aged 40 years and older
suspected malignant mass arising from the urinary tract.

21. Who to refer ? suspected urogenital fistulae
previous continence surgery
previous pelvic cancer surgery
previous pelvic radiation therapy

22. Who to refer ? persisting bladder or urethral pain
clinically benign pelvic masses
associated faecal incontinence
suspected neurological disease
symptoms of voiding difficulty

23. Take home message Only treat SYMPTOMATIC prolapse Physiotherapy
Rule out other causes of overactive bladder symptoms
Frequency / volume charts
Anticholinergics