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

Department Consultants Other doctors Continence nurse advisors Physiotherapists Urodynamics Team

Uro - gynae - cology Prolapse Stress incontinence Overactive bladder

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

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

Prolapse staging

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

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

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

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

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

Anticholinergic drugs Oxybutynin Tolterodine Trospium chloride Solifenacin Fesoterodine Darifenacin

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 2013. BET13018UK

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

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

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

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.

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

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

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