1. Urinary Incontinence (UI) Management in Family Practice References: Can Fam Physician 2003;49:611-618. Can Fam Physician 2003;49:602-610. SOGC Clinical Practice Guidelines. No. 127, April 2003.

2. To do:  Info  Types of Incontinence  What to do in office  Treatment  When to refer

3. Info  1.5 million Canadians  12% of women, 2% of men >55  Affects Quality of Life  Majority can be managed by Family Physician

4. Types of Incontinence  Stress  Urge  Mixed  Overflow

5. Stress Incontinence  Most common  Loss of urine on physical exertion or increases in intra-abdominal pressure.  Usually no nocturia (helps distinguish from urge incontinence)

6. Urge Incontinence (overactive bladder)  Loss of urine with strong desire to void. Frequency and nocturia are common  Pure urge incontinence is least common (3% adult women)

7. Mixed UI (urge + stress)  Loss of urine with both urge and increases in abdominal stress.

8. Overflow  Associated with bladder distention or retention; poorly contractile detrusor or outlet obstruction  Chronic retention is usually painless  Can be confused with stress incontinence because leakage can occur with increase abdominal pressure

9. What to do in Office?  Ask about it on annual  precipitating factors, amount, frequency, protective measures (pads, clothing changes), Quality of Life  Fluid Intake, caffeine, HS fluids?, previous surgeries, smoke, ? Sx of UTI, constipation  Meds: Ace (cough), diuretics, alpha- blockers  Causing retention: hypnotics, antipsychotics, narcotics, anticholinergics

10. Voiding diary

11. Basic Physical Exam/Labs  Neurological exam  Urinary Stress Test  Speculum and Bimanual Pelvic  Urine Dip/R&M

12. Treatment 1.Lifestyle: fluid/caffeine, UTI, constipation, void regularly, lose weight, stop smoking 2.Pelvic Floor Strengthening: benefit urge, stress, and mixed UI. Success in 50-90% of patients 3.Bladder Training (Urge Suppression or scheduled voiding)

13. Kegel (Pelvic Floor Muscle) Exercises  Squeeze (as if stopping urination)  Hold for 5s, relax for 10s. Repeat x10 TID.  15 contractions TID  20 contractions QID + 20 whenever

15. Specific Treatment for Stress Incontinence  Pessary: for Stress Incontinence +/- Prolapse Specific Treatment for Mixed/Urge  Muscarinic Receptor Antagonists OXYBUTYNIN: Ditropan® XL 5 mg Transdermal: Adults: Apply one 3.9 mg/day patch twice weekly (every 3-4 days) TOLTERODINE: Detrol® 2 mg BID or 4 mg Daily of Long Acting (LA)

16. When to Refer  No or partial response to conservative measures  Previous prolapse surgery  Previous continence surgery that has failed  Severe pelvic organ prolapse  Voiding dysfunction with high postvoid residual urine (with or without complications: recurrent UTI, hydronephrosis)