Urinary Incontinence Kieron Durkan GPST 1

Aims Definitions Overactive Bladder Syndrome Stress Incontinence Urge Incontinence Risk Factors Treatments Guidelines

Introduction Urinary Incontinence (UI) common cause of referral to gynae clinics. Prevalence of incontinence occurring twice or more a month 8.5% in women aged 16 – 65 and 11.6% > 65. Suggested that this is underestimated and likely up to 3 million women in UK suffering, of which < 20% receive any investigation.

Definitions International Continence Society define as ‘the complaint of any involuntary leakage of urine’. Stress UI: involuntary leakage on effort or exertion eg coughing / sneezing Urge UI: involuntary leakage accompanied or immediately preceded by urgency Mixed UI: involuntary leakage associated with both exertion and urgency, effort, sneezing or coughing.

Overactive Bladder Syndrome Urgency that occurs with or without urge UI and usually with frequency and nocturia. ‘Wet’: OAB occurring with urge UI ‘Dry’: OAB without urge UI. May be due to detrusor overactivity.

Stress Incontinence Due to an increase in intra-abdominal pressure and in absence of detrusor activity. Defect of urethral sphincter Severity is graded: Severe stress eg coughing, sneezing, jogging Moderate stress eg walking up and down stairs Mild stress eg standing

Urge Incontinence Occurs when the sudden desire to void is overwhelming. Detrusor instability is a common cause.

Risk Factors Pregnancy and Childbirth risk highest in first pregnancy then increases slightly with each further. High-Impact Exercise (increase shock to pelvic area) Smoking Obesity Urge more common in diabetes, hysterectomy and recurrent UTIs.

History Taking Key points to ask: What happens? How often? What doing at the time? How much urine? Rule out other causes eg diabetes, anxiety, UTI, carcinoma, alcohol, caffeine, drugs Full gynae and obstetric history, noting parity and types of delivery.

Examination Key points: Neurological exam, paying particular attention to lower limb sensation, tone, power and reflexes. Abdominal examination Pelvic Exam: Attention to urethra and bladder neck Digital assessment of pelvic floor muscles Any obvious prolapse.

Management (NICE Guidelines) Initial Assessment Categorise Create a bladder diary for at least 3 days Dip urine (blood, glucose, nitrites, leuc, protein) If urge or OAB then advise lose weight if BMI > 30 and modify fluid intake.

Management of Stress UI First line for stress or mixed UI should be PFMT lasting at least 3 months. 8 contractions at least 3 times a day Discuss benefits of non-surgical v surgical, refer onwards if requesting surgical. Urodynamics not necessary in pure stress incontinence. Surgical options: Retropubic mid-urethral tape Synthetic slings Intramural bulking agents by injection

Management of Urge UI or OAB First line treatment should be bladder training lasting at least 6 weeks. If frequency still remaining then consider an anti-muscarinic drug. Be aware of CIs/SEs. If training ineffective then prescribe oxybutynin (alternatives are darifenacin, solifenacin, tolterodone). If still not controlled refer for Urodynamic studies.

Non-Conservative Management of Urge UI or OAB If conservative methods have failed then consider: Botulinum A toxin to treat detrusor overactivity if willing to self-catheterise Sacral nerve stimulation Augmentation cytoplasty Urinary diversion

Indications for Referral Urgent: Microscopic haematuria if > 50 Visible haematuria Recurrent or persistent UTI associated with haematuria if > 40 Suspected pelvic mass arising from urinary tract Non-urgent: Symptomatic prolapse visible at or below vaginal introitus Palpable bladder on bimanual or physical examination after voiding.

Consider referring: Persisting bladder or urethral pain Clinically benign pelvic mass Assoc faecal incontinence Suspected neurological disease Voiding difficulty Suspected urogenital fistulae Previous continence surgery Previous pelvic Ca surgery Previous pelvic radiation therapy

Conclusions There is stress incontinence, urge incontinence and OAB. Work out which the patient has and may be mixed! Treat conservatively to start with and involve patient in all decision making If pelvic floor / bladder training / anticholinergic/oxybutynin is insufficient then refer for specialist involvement. There are some categories of urgent referral to be aware of.

Thank You References 1) NICE. Urinary Incontinence. 2006. 2) www.gpnotebook.com . Urinary Incontinence. 3) University of Maryland. Urinary Incontinence Risk factors. www.umm.edu