1. Disability and Incontinence Patient assessment Patient management

2. Incontinence is more common in disabled Major effect on QoL Major economic burden Increasing issue as survival improves Leads to isolation, depression and death

3. Overall management Individual patient focussed Coordinated multidisciplinary Community based Realistic Cost effective Ongoing care Improved QoL, Independence …small interventions can lead to major improvements……

4. Urinary Incontinence Physical decline General decline Vicious cycle

5. Causes of Incontinence SUI Stress Incontinence : 50% UUI Urge Incontinence : 20% MUI Mixed Incontinence: 30% Higher UUI in Disabled Non Urinary tract Ageing Reduced mobility Poly pharmacy Iatrogenic Psychogenic Cognitive impairment

6. Causes of Incontinence D Delirium I Infection A Atrophic vaginitis P Psychogenic P Pharmacologic E Excess urine R Restricted mobility S Stool impaction

7. Assessement Systematic History Examination Investigations Diagnosis / define goals Treatment Follow up

8. History General: Medical, systems, social supports, environmental Specific: Urinary symptoms, Incontinence severity, current management.

9. Examination General : Mobility, IQ/ cognition, BMI, Hand function Specific : Focused neurology, Abdominal, Pelvic floor ( Prolapse / Incontinence ), Rectal ( Constipation )

10. Investigations MSU : Haematuria, UTI Bloods : Creatinine, Glucose, Ca++ Flow and Residual Bladder diary [ 24 hrs vs 3 days ] Think Compliance and cooperation QoL Score ICIQ ( useful - not validated ) Renal US Urodynamics: Rarely required ( pre op )

11. Diagnosis and management plan Patient/ care giver expectation Ability to deliver Know local referral pathways Additional Chronic pain: adds to difficulty Haematuria : referral UTI : Treat and review Prolapse : Refer

12. Levels of evidence Grades of recommendation

13. Outcome objectives

14. Management strategy Clinical / physical Drugs Environmental Behavioral / Social Rehabilitate Integrate support

15. Success in caregiver management Under pinning: Life long love….. Problem solve: careful observation Consequences: role change, emotional change, financial change, sleep, social isolation, reduced intimacy

16. Management UUI General: Scheduled void [ b ], restrict fluids [ b ], stop smoking [ c ], avoid caffeine [ a ] Specific: Bladder retraining [ a ] 70% Anticholinergics [ a ] 70% ( low dose, not in retention, glaucoma ) ; new B3 agonist

17. Management UUI Neuromodulation: Sacral vs Post tibial [ a ] 60 – 80% expensive, intensive required expertise Botox: [ a ] 75% expensive, repeated 6 – 12 monthly, may cause retention Catheter: patient preference depends on mobility Augmentation: rarely required

18. Management SUI : Female General: timed void [b ], reduce caffeine [ a ], reduce weight [ b ], reduce fluids [ b ], reduce smoking [ b ]. Specific: Pelvic floor exercises [ a ] 30%, oestrogen cream [ c ] 30%, surgery [ a ].

19. Sling procedures for female SUI Grade A evidence 75 – 90% cure 10 yrs durable First choice Similar outcomes in disabled / elderly Low risk retention

20. Management Male SUI Majority Post RRP Wait 6 – 12 months AUS ACC coverage in NZ 90% dry or 1 security pad Male sling for lower volume incontinence 60% effective Long term catheter or diversion

21. Management mixed UI Manage predominant symptoms first in step wise manner Lower success

22. Summary Listen and set realistic goals “3 day trial” and review Modify plan if required Refer if complex or fail Remember…. A small intervention can lead to a major improvement…..