Urinary Incontinence

Victoria Cook

Consultant in obstetrics and Gynaecology

The Hillingdon Hospital

Objectives

• Make a provisional diagnosis of cause of incontinence

• Formulate appropriate management plan

• When to refer

• Who to refer to

Incontinence in Women

• Major impact on quality of life– Fear of cough / cold– Stop exercising– Avoidance of sex– Fear of odour– Worry about pads – cost, visibility, leakage– Limitations of clothing– Toilet mapping– Housebound

• Yet may take years to present for help– Embarassment– Acceptance that it is normal after having kids

Definitions (ICS 2002)

• Over active bladder– Urgency with or without urge incontinence, usually

accompanied by frequency and nocturia

• Urge incontinence– Involuntary leakage accompanied by or immediately

preceded by urgency

• Stress incontinence– Involuntary leakage on effort or exertion or on sneezing

or coughing

• Urgency: The complaint of a sudden, compelling desire to pass urine, that is difficult to defer

• Frequency: Usually accompanies urgency with or without urge incontinence. Refers to a patient’s complaint of voiding too often by day

• Nocturia: Usually accompanies urgency with or without urge incontinence. Patient has to wake at night one of more times to void

1. Abrams P et al. Urology 2003;61:37-49

Differential diagnosis

Normal Bladder OAB Stress Incontinence

Stress Incontinence or Overactive Bladder?

• Leakage– What makes her leak– how much– Pad usage

• Frequency of Micturition• Nocturia• Urinary Urgency• Bedwetting• Sex

Stress Incontinence or Overactive Bladder?

• Examination– Abdominal mass– Pelvic mass– Prolapse– Leakage seen on coughing– Vulval hygiene

• Investigations– MSU– Frequency volume chart

• (Urodynamics)

Management of Urinary Incontinence

• Behavior modification• Bladder retraining• Weight loss• Pelvic floor exercises• Fluid management – what, when, how much• Reduction in caffeine

• Bladder and bowel foundation – www.bladderandbowelfoundation.org– Just can’t wait toilet card (£5)

Management of Overactive Bladder

Treatment of Overactive Bladder

• Conservative measures• Review all other medication which may be

exacerbating symptoms– Diuretics– Amlodipine– Other antihypertensives

• Anticholinergics– Contraindicated with glaucoma

• (Botox)

NICE GUIDANCE

• Treat predominant symptom• Oxybutynin Hydochoride

– Cheap– Works well– Side effect profile can be a problem– All other anticholinergics have been developed to improve

side effects

• Reasonable first line as long as – patient aware there are alternatives– Patient can be reviewed within 6 weeks to ensure they are

tolerating the drug

Which Anticholinergic?

• (Detrusitol (tolterodine) 4mg XL)• Vesicare (solifenacin) 5mg or 10mg• Lyrinel (oxybutynin) XL 5mg, 10mg, 15mg or

20mg• Kentera (oxybutynin) patches• Emselex (darifenacin) 7.5mg or 15mg • Toviaz (fesoterodine) 4mg or 8mg

• Regurin (trospium) 20mg twice daily

Which Anticholinergic?Vesicare 5mg increasing to

10mg if necessary and if tolerated

Lyrinel in increasing doses if no success

with Vesicare

Kentera if side effects a problem with

Vesicare

Emselex if IBS or bowel problems

Exacerbated by Vesicare

Botox

• Unlicensed• Seems to be very effective• Multiple injections into the detrusor muscle via

cystoscopy• Evidence of long term safety in other disciplines• But needs repeat injections approx 12 monthly• Expensive!

Treatment of Stress Incontinence

Treatment of Stress Incontinence

• Life style advice

• Physiotherapy

• Duloxetine

• Surgery– TVT– Bulkamid bladder neck injections– Colposuspension

Stress Incontinence

• Yentreve (duloxetine) – Start at 20mg twice daily– Increase to 40mg twice daily after 2 weeks– This is to reduce side effects– It is working at level of urinary sphincter– NOT by reducing depression!– Patients either love it or hate it

Surgery

• TVT– Over night stay– Good success rates 80-90%– 2 weeks off work– Risks of urgency, poor voiding, tape erosion

• Bulkamid– Bladder neck injection – polyacrylamide hydrogel– Day case / overnight stay– Long term results unknown– Useful in mixed incontinence, young, old, failed TVT

Mixed Incontinence

• Lifestyle advice

• Physiotherapy

• Treat overactive bladder

• Duloxetine can be very useful

• I try to avoid surgery as they do badly

• Now using Bulkamid – time will tell!

When to Refer

• Overactive bladder– If patient not responding or unable to tolerate

anticholinergic (oxybutynin plus one other)

– Glaucoma

• Stress incontinence– If patient doesn’t respond to pelvic floor exercises

(preferably with physiotherapist)

• Prolapse• Other factors

Who To Refer To?

Urogynaecology

Prolapse FibroidsOther gynae issues

Urology

NeurologyBotox

Bladder painOther pathology

Both

Stress incontinenceOveractive bladder

Recurrent UTI

Any Questions?

I can be contacted on:victoria.cook@thh.nhs.uk