Urinary Incontinence

Tova Ablove, Alev Wilk Tova Ablove, Alev Wilk

Primary Care Conference, 6/22/05Primary Care Conference, 6/22/05

Urinary Incontinence

No Financial DisclosuresNo Financial Disclosures

Objectives

Overview of Urinary Incontinence in Overview of Urinary Incontinence in Women: Dr. AbloveWomen: Dr. Ablove

Presentation of Cases: Dr. WilkPresentation of Cases: Dr. Wilk Initial Management Issues:Initial Management Issues:

Urodynamic testing for all women? OR Urodynamic testing for all women? OR Therapy trials based on history and exam Therapy trials based on history and exam

only: medication, pelvic floor exercises, only: medication, pelvic floor exercises, pessary?pessary?

Incontinence

14% of healthy postmenopausal have daily 14% of healthy postmenopausal have daily incontinence. incontinence.

41% of healthy postmenopausal have 41% of healthy postmenopausal have incontinence at least once per month. incontinence at least once per month.

Brown et al. obstetrics and gynecology Brown et al. obstetrics and gynecology 19961996

Types of Urinary Incontinence Mixed symptoms

– combination of stress and urge incontinence

Urge

– urine loss accompanied by urgency resulting from abnormal Bladder contractions

Stress– urine loss resulting from

sudden increased intra-abdominal pressure (eg, laugh, cough, sneeze)

Sudden increasein intra-abdominalpressure

Uninhibited detrusorcontractionsUrethral pressure

Urinary Incontinence and OAB

z • Urgency• Frequency• Nocturia

SUI Mixed(UUI+SUI)

UUI

OABOAB

Detrol® LA

Evaluation

HistoryHistory PhysicalPhysical LabsLabs TestingTesting

History

HPIHPI Identify #1 complaintIdentify #1 complaint Frequency & duration Frequency & duration

of sxof sx Medications Medications Musculo-skeletalMusculo-skeletal

Mobility- screen for Mobility- screen for fallsfalls

Back pain/diseaseBack pain/disease

AutoimmuneAutoimmune MSMS FibromyalgiaFibromyalgia IBSIBS CrohnsCrohns

Heart failureHeart failure Neurologic/psychiatricNeurologic/psychiatric

Stroke, depression, Stroke, depression, dementiadementia

History

DiabetesDiabetes Gynecologic Gynecologic

Hormonal statusHormonal status ProlapseProlapse STDsSTDs Sexual activitySexual activity PregnancyPregnancy Chronic pelvic painChronic pelvic pain

Bladder diseaseBladder disease Interstitial cystitisInterstitial cystitis CancerCancer Chronic cystitisChronic cystitis

Kidney diseaseKidney disease InfectionsInfections StonesStones InsufficiencyInsufficiency

Physical Examination

Perform general, abdominal (including Perform general, abdominal (including bladder palpation), and neurologic exams bladder palpation), and neurologic exams

Perform pelvic and rectal exam in females Perform pelvic and rectal exam in females and rectal exam in males and rectal exam in males

Observe for urine loss with vigorous coughObserve for urine loss with vigorous cough Check for urinary retention Check for urinary retention

Fantl JA et al. Managing Acute and Chronic Urinary Incontinence. Clinical Practice Guideline. Quick Reference Guide for Clinicians, No. 2, 1996 Update. Rockville, MD: Agency for Health Care Policy and Research; January 1996. AHCPR publication 96-0686.

Pelvic Anatomy

Pelvic Exam

Laboratory Tests UrinalysisUrinalysis

to evaluate for hematuria, pyuria, bacteriuria, to evaluate for hematuria, pyuria, bacteriuria, glucosuria, proteinuriaglucosuria, proteinuria

Urine cultureUrine culture Wet mountWet mount Vaginal cultures Vaginal cultures Herpes cultures not usually done on initial evaluationHerpes cultures not usually done on initial evaluation Blood work if compromised renal function is Blood work if compromised renal function is

suspectedsuspected

Treatments

Treat patient’s most bothersome form of Treat patient’s most bothersome form of voiding dysfunction first. voiding dysfunction first.

Treat conditions that can mimic or Treat conditions that can mimic or exacerbate overactive bladderexacerbate overactive bladder

The objective is to improve quality of life.The objective is to improve quality of life.

Treatable Conditions That Mimic or Exacerbate OAB

Urinary tract infectionUrinary tract infection Urogenital agingUrogenital aging Bladder outlet obstructionBladder outlet obstruction Prolapse *Prolapse * Stress incontinence *Stress incontinence *

Treatments

Overactive bladderOveractive bladder Drugs anticholinergic, local estrogen Drugs anticholinergic, local estrogen Pelvic floor rehabPelvic floor rehab Bladder drillBladder drill Treat bladder outlet obstructionTreat bladder outlet obstruction Acupuncture Acupuncture Neuromodulation Neuromodulation Botox injectionsBotox injections

Drugs

Predominant anticholinergic or antimuscurinic Predominant anticholinergic or antimuscurinic action action

OxybutninOxybutnin TolterodineTolterodine HyoscyamineHyoscyamine ImipramineImipramine DarifenacinDarifenacin SolifenacinSolifenacin

Close follow up needed especially in geriatric Close follow up needed especially in geriatric patients patients

Treatments: Stress Incontinence

Pelvic floor rehabilitationPelvic floor rehabilitation Local estrogenLocal estrogen Incontinence pessaryIncontinence pessary CollagenCollagen Surgery Surgery

OAB: When to Consider Referral to a Specialist Symptoms do not respond to initial treatment Symptoms do not respond to initial treatment

within 2–3 monthswithin 2–3 months Hematuria without infection on urinalysisHematuria without infection on urinalysis Symptoms suggestive of poor bladder emptying Symptoms suggestive of poor bladder emptying

(hesitancy, poor stream, terminal dribbling)(hesitancy, poor stream, terminal dribbling) Evidence of unexplained neurologic or Evidence of unexplained neurologic or

metabolic diseasemetabolic disease Significant pelvic organ prolapse is presentSignificant pelvic organ prolapse is present

Abrams P, Wein AJ. The Overactive Bladder:A Widespread and Treatable Condition. Erik Sparre Medical AB; 1998.

Stress Incontinence: When to Consider Referral to a Specialist

If patient desires treatment and is not If patient desires treatment and is not interested in conservative therapy or has interested in conservative therapy or has tried and failed conservative therapy.tried and failed conservative therapy.

When to refer for Cystoscopy

To rule out stones, cancer, foreign bodies, To rule out stones, cancer, foreign bodies, chronic inflammation chronic inflammation

To confirm normal anatomy prior to surgery.To confirm normal anatomy prior to surgery. Recurrent UTIs especially if they are resistant to therapyRecurrent UTIs especially if they are resistant to therapy HematuriaHematuria Irritative bladder symptoms especially in postmenopausal Irritative bladder symptoms especially in postmenopausal

women and smokerswomen and smokers Recurrent incontinenceRecurrent incontinence With suspicion of interstitial cystitisWith suspicion of interstitial cystitis

When to Refer for Urodynamics?

Urinary retentionUrinary retention Incontinence that fails initial therapyIncontinence that fails initial therapy History of Neurologic diseaseHistory of Neurologic disease Prolapse desiring surgery Prolapse desiring surgery Prolapse as part of the clinical picture of Prolapse as part of the clinical picture of

incontinenceincontinence Prior pelvic surgeryPrior pelvic surgery Mixed incontinenceMixed incontinence

1996 Agency for Health Care Policy and ResearchWeider et al 2001Handa et al 1995

Case One

48 y.o. woman with polyuria (every 30 minutes 48 y.o. woman with polyuria (every 30 minutes while awake) and pelvic pressure for 6 monthswhile awake) and pelvic pressure for 6 months

Voiding diary- frequency 16x/24hrs, nocturia 1-Voiding diary- frequency 16x/24hrs, nocturia 1-2x/night, no leak episodes2x/night, no leak episodes

No dysuria, postvoid fullness, constipationNo dysuria, postvoid fullness, constipation Three uncomplicated vaginal births; tubal ligation; Three uncomplicated vaginal births; tubal ligation;

Leep procedure 1993Leep procedure 1993 Premenstrual syndrome dysphoria on fluoxetinePremenstrual syndrome dysphoria on fluoxetine

Case One

Denies tobacco or alcohol use; CNADenies tobacco or alcohol use; CNA Exam: NL cardiovascular, GI, Kidney. Genital: Exam: NL cardiovascular, GI, Kidney. Genital:

pelvic floor “prolapse to introitus”; negative UA pelvic floor “prolapse to introitus”; negative UA & glucose; PVR: 100cc.& glucose; PVR: 100cc.

Recommendations: Recommendations: Oxybutinin for “overactive bladder”?Oxybutinin for “overactive bladder”? Pelvic Floor Physical Therapy Program?Pelvic Floor Physical Therapy Program? Referral to subspecialty?Referral to subspecialty?

Case Two

76 y.o. woman with stress and urge incontinence, 76 y.o. woman with stress and urge incontinence, urinary leakage; nocturia 1-2x per nighturinary leakage; nocturia 1-2x per night

Urinary frequency, constipation, postvoid fullnessUrinary frequency, constipation, postvoid fullness G6P6; s/p oophorectomy, partial colectomyG6P6; s/p oophorectomy, partial colectomy Depression, COPD, HTN, schizophrenia, anxietyDepression, COPD, HTN, schizophrenia, anxiety Current smoker: 63 pack years; no alcohol; retired Current smoker: 63 pack years; no alcohol; retired

RN and widowedRN and widowed

Case Two

Albuterol, cogentin, valium, benadryl, depakote, Albuterol, cogentin, valium, benadryl, depakote, advair, meclizine, zyprexa, piroxicam, quinine, advair, meclizine, zyprexa, piroxicam, quinine, risperidone, trazodonerisperidone, trazodone

Exam: Stable cardiovascular, GI, Kidney. Genital: Exam: Stable cardiovascular, GI, Kidney. Genital: vaginal atrophy; negative UA. PVR 60cc.vaginal atrophy; negative UA. PVR 60cc.

Recommendations: Recommendations: Estrogen? Estrogen? Pelvic Floor Physical Therapy Program?Pelvic Floor Physical Therapy Program? Referral to subspecialty?Referral to subspecialty?

Case Three

55 y.o. woman with stress incontinence when she 55 y.o. woman with stress incontinence when she coughs, laughs, or exercisescoughs, laughs, or exercises

No dribbling, urgency, frequency, dysuria, No dribbling, urgency, frequency, dysuria, postvoid fullness, constipationpostvoid fullness, constipation

GG00PP00

Depression on CelexaDepression on Celexa

Case Three

Denies tobacco or alcohol use; Recently divorcedDenies tobacco or alcohol use; Recently divorced Exam: NL cardiovascular, GI, Kidney. Genital: Exam: NL cardiovascular, GI, Kidney. Genital:

vaginal atrophy; negative UA. PVR 60cc.vaginal atrophy; negative UA. PVR 60cc. Recommendations: Recommendations:

Estrogens? Estrogens? Pessary? Pessary? Pelvic Floor Physical Therapy Program?Pelvic Floor Physical Therapy Program? Referral to subspecialty?Referral to subspecialty?

Case Four

44 y.o. woman with stress incontinence and 44 y.o. woman with stress incontinence and urinary leakage, nocturia x2 at nighturinary leakage, nocturia x2 at night

No dribbling, urgency, frequency, dysuria, No dribbling, urgency, frequency, dysuria, constipationconstipation

Four vaginal, uneventful vaginal deliveries; Four vaginal, uneventful vaginal deliveries; hysterectomy and bladder suspension procedure hysterectomy and bladder suspension procedure 19901990

HTN, fibromyalgia, GERD on ranitidine and HTN, fibromyalgia, GERD on ranitidine and atenololatenolol

Case Four

Denies tobacco or alcohol use; CNADenies tobacco or alcohol use; CNA Exam: NL cardiovascular, GI, Kidney. Genital: Exam: NL cardiovascular, GI, Kidney. Genital:

atrophic vulva & pelvic floor laxity; negative UA. atrophic vulva & pelvic floor laxity; negative UA. PVR 40cc.PVR 40cc.

Has attempted Kegel exercises without Has attempted Kegel exercises without improvementimprovement

Recommendations: Recommendations: Medications? Pessary? Medications? Pessary? Pelvic Floor Physical Therapy Program? Pelvic Floor Physical Therapy Program? Referral to subspecialty?Referral to subspecialty?

Case Five

36 y.o. woman with stress incontinence recently 36 y.o. woman with stress incontinence recently exacerbated by URI symptomsexacerbated by URI symptoms

No dribbling, urgency, frequency, dysuria, No dribbling, urgency, frequency, dysuria, postvoid fullness, constipation. postvoid fullness, constipation.

GG55PP55, s/p C-section 1988, s/p C-section 1988

Intermittent asthma, neck painIntermittent asthma, neck pain Ortho evra patch, prn maxair, skelaxinOrtho evra patch, prn maxair, skelaxin

Case Five

Denies tobacco or alcohol use; Bus driverDenies tobacco or alcohol use; Bus driver Exam: NL cardiovascular, GI, Kidney. Genital: Exam: NL cardiovascular, GI, Kidney. Genital:

grossly normal; negative UA. PVR 20ccgrossly normal; negative UA. PVR 20cc Has attempted Kegel exercises without Has attempted Kegel exercises without

improvementimprovement Recommendations: Recommendations:

Medications? Pessary? Medications? Pessary? Pelvic Floor Physical Therapy Program?Pelvic Floor Physical Therapy Program? Referral to subspecialty?Referral to subspecialty?