Urinary Incontinence and Prolapse Incontinence and prolapse
commonly coexist But, they do not always share a common cause or a
common treatment
Slide 4
Types of Urinary Incontinence: Stress incontinence Urge
incontinence Mixed Chronic urinary retention and overflow
incontinence Miscellaneous (UTI, dementia, fistulae)
Slide 5
Slide 6
NICE Guidelines (October 2006) Woman presents with urinary
incontinence Categorise as Stress incontinence Urge
incontinence/Overactive bladder Mixed stress and urge Start
treatment on that basis
Slide 7
NICE Guidelines Initial Assessment (stress, urge, mixed)
Identify factors that need referral Ask woman to complete a bladder
diary for 3 days Urine dipstick for glucose, protein, leucocytes
and nitrites
Slide 8
Frequency / Voiding chart Keep chart for 3-7 days Gives an idea
of fluid intake Useful in explaining to patient about changes to
intake
Slide 9
Advice about lifestyle factors High or Low fluid intake (from
intake/output fluid charts) Weight loss if BMI > 30
Slide 10
Increased Intra-abdominal Pressure: Pregnancy Pulmonary disease
smokers cough Constipation/straining Lifting work and home Exercise
Obesity
Slide 11
Stress Incontinence Refer to continence advisor / specialist
physio for at least 3 months. (should know by 3-6 months if
improvement) If improvement inadequate, refer to secondary care
surgery or duloxitene (Yentreve) (by protocol)
Slide 12
Pelvic Floor Exercises
Slide 13
Urge incontinence / Over-active bladder Reduce caffeine intake
In postmenopausal women prescribe local vaginal estrogen cream,
vaginal tablets, ring Refer to continence advisor for bladder
training If ineffective consider oxybutinin or alternatives If
ineffective, refer to secondary care for urodynamic investigation /
further treatment
Slide 14
Drug treatment for urgency/OAB oxybutinin OR clarifenacin
solifenacin tolterodine trospium different oxybutinin
formulations
Slide 15
Mixed incontinence Treat whichever symptom predominates (what
is your worst problem?)
Slide 16
Urgent referrals (2 week wait) Microscopic haematuria in women
aged 50 and over - urology Vsible haematuria urology Recurrent or
persisting UTI associated with haematuria in women aged 40 and
older urology Sspected malignant mass arising from urinary/genital
tract urology or gynaecology
Slide 17
Indications for referral Symptomatic prolapse that is visible
at or below the vaginal introitus gynaecology The finding of a
palpable bladder on bimanual or abdominal examination after voiding
urology or gynaecology
Slide 18
Consideration for referral Persisting bladder or urethral pain
urology or gynaecology Clinically benign pelvic masses gynaecology
Associated faecal incontinence gynaecology/colorectal Suspected
neurological disease neurology, urology, gynaecology Symptoms of
voiding difficulty urology or gynaecology
Slide 19
Consideration for referral Suspected urogenital fistulae
urology or gynaecology Previous continence surgery gynaecology or
urology Previous pelvic cancer surgery gynaecology or urology
Previous pelvic irradiation gynaecology or urology
Slide 20
Conditions requiring referral to secondary care or specialist
unit Uncertain diagnosis, no clear treatment plan Unsuccessful
treatment Patient requests further treatment Surgery contemplated
or previous surgery failed Haematuria without infection Symptomatic
prolapse
Surgical treatment for incontinence Discussion Benefits Success
rate Associated improvements Quality of life Risks Surgical
Development of overactive bladder Quality of Life
Slide 23
Surgical treatment for incontinence - operations Tension-free
Vaginal Tape (TVT) Relatively simple technique Inserted under local
anaesthetic Day Case Quick return to work about 2 weeks Good
initial success both as primary and secondary procedure Long-term
success figures up to 11 years
Slide 24
TVT tension free vaginal tape
Slide 25
TOT - Transobturator Tape
Slide 26
Prolapse
Slide 27
4 options Do nothing if asymptomatic Physiotherapy if minor
(stage 1) Vaginal support pessaries suit some Surgery Traditional
vaginal repair Newer meshes
Slide 28
Menopause and HRT
Slide 29
HRT, where are we now? Up to 2002 Widespread HRT use 2002
Womens Health Initiative Study Million Women Study CSM advice 2002
- present Further reanalysis since still ongoing HRT use fallen by
50% but now used more appropriately
Slide 30
Observational Studies of HRT Reduction in symptoms (flushes,
sweats, emotional, vaginal dryness) Reduction in risk of Coronary
Heart Disease Reduction in osteoporotic fractures Increase in risk
of thrombosis Increase in risk of breast cancer Reduction in risk
of colo-rectal cancer
Slide 31
WOMENS HEALTH INITIATIVE RCT Designed to last for 8.5 years
look at major health benefits and risks associated with the most
commonly used HRT in the US i.e. CEE +/- MPA against placebo JAMA
2002; 288: 321-33
Slide 32
Risk of Hip fracture effects of E+P vs E alone E+P E alone
Slide 33
Risk of invasive breast cancer effects of E+P vs E alone E
alone E+P
Slide 34
Risk of Coloectal cancer effects of E+P vs E alone E alone
E+P
Slide 35
Risk of coronary heart disease effects of E+P vs E alone E
alone E+P
Slide 36
Risk of Stroke effects of E+P vs E alone E alone E+P
Slide 37
Hazard ratios from WHI trialsClinicalEventWHIE+P WHI E alone
CHD 1.29 (1.02-1.63) (1.02-1.63)0.91(0.75-1.12)
Stroke1.41(1.07-1.85)1.39 (1.10-1.77) (1.10-1.77) PE2.13
(1.39-3.25) (1.39-3.25)1.34(0.87-2.06) Breast cancer
1.26(1.00-1.59)0.77(0.59-1.01) Colon cancer
0.63(0.43-0.92)1.08(0.75-1.55) Hip fracture 0.66 (0.45-0.98)
(0.45-0.98)0.61(0.41-0.91) Death0.98 (0.82-1.18)
(0.82-1.18)1.04(0.88-1.22) Global index 1.15(1.03-1.28)1.01
(0.91-1.12) (0.91-1.12) Risk Possible risk/benefit Benefit
Slide 38
CSM advice for HRT December 2002 Benefits of short term HRT
outweigh risks (up to 2-3 years) If using long term HRT for
symptoms, discuss with doctor on a regular basis (at least once a
year) Do not use HRT simply to prevent cardiovascular disease
December 2003 Do not use HRT as first line treatment for
osteoporosis unless other indications symptoms Current Use HRT at
minimum effective dose for shortest duration i.e. use HRT for as
long as necessary to achieve the objectives of treatment (symptom
relief), but keep dose to a minimum
Slide 39
What do we tell patients now?
Slide 40
What does HRT do to your risk of developing certain diseases?
Reduction in symptoms (flushes, sweats) Reduction in osteoporotic
(hip) fractures Increase in risk of thrombosis (blood clots) with
oral HRT (but probably not with non-oral preparations) Increase in
risk of breast cancer with combined HRT (but probably not with
estrogen only HRT) Reduction in risk of bowel cancer with combined
HRT Increase in stroke and heart attacks in elderly patients,
probably on starting any HRT
Slide 41
Regimens of HRT Oestrogen only - systemic Combined sequential E
+ P Continuous combined E + P Tibolone (Livial) Long cycle E + P (3
monthly) Estrogen with MIRENA IUS Local estrogen tablets, creams,
pessaries
Slide 42
Who needs HRT? Premature ovarian failure (early menopause) No
randomised data but observational data suggest good protection HRT
or the pill are helpful Risks of breast cancer - by 50, risk is the
same as if had periods to 50 i.e. it is the lifetime duration of
exposure to oestrogen and progestogen which is important
Slide 43
Who needs HRT? Symptomatic women Very few contraindications to
HRT Estrogen dependent cancer Current or high risk of thrombosis
(use non-oral) High risk of cardiovascular disease (?use non-oral)
Side effects will occasionally restrict use
Slide 44
How long should a woman take HRT for?
Slide 45
Duration of HRT It depends on the indication(s) for HRT
Premature menopause Continue at least until age 51 May need much
higher doses at a young age Symptoms flushes 80% ended at 5 years
vaginal dryness continues for life but may cease to be a problem
The body responds to lower doses of HRT as the woman gets
older
Slide 46
Duration of HRT Breast cancer Clear duration dependent
increased risk with E+P, commences after the first 4 years of
treatment Overall mortality may not be increased Possibly no
increased risk with E only HRT Risks vary with Family history
Personal history of premalignant changes
Slide 47
Duration of HRT INDIVIDUALISE A good policy is to review risks
vs benefits at 2 years and annually after that Allow patients to be
guided by quality of life issues if coming off HRT causes a poor
quality of life, discuss risks vs benefits (for them) restart if
they wish Aim for lowest effective dose
Slide 48
Stopping HRT For women who have been on HRT for >1 year,
best to reduce dose gradually. If initial indication was not for
symptom relief, may stop treatment abruptly.
Slide 49
Ten tips to treating the menopause 1) Counselling for HRT -
risks Breast cancer Related to duration of treatment Probably no
increased risk with estrogen only HRT ThrombosisRisk 2-3 / 10,000
per year Risk greatly with patch/gel (non oral) StrokeRisk for
older age group/hypertensive Dose related CV diseaseRisk in older
patients commencing HRT
Slide 50
Ten tips to treating the menopause 2) Counselling for HRT
benefits Menopausal symptoms relieved Quality of life improvements
Osteoporosis/fractures reduced Bowel cancer, reduced risk (E+P
treatment)
Slide 51
Ten tips to treating the menopause 3) Take care with Hormone
dependent cancers Previous or high risk of thrombosis (non-oral)
High risk CV disease Abnormal bleeding
Slide 52
Ten tips to treating the menopause 4) If shes had a
hysterectomy its easy Treat with estrogen only HRT Titrate dose
against symptoms Benefits >> risks generally No increased
risk breast cancer (WHI study) No decreased risk bowel cancer
Slide 53
Ten tips to treating the menopause 4) If shes had a
hysterectomy its easy Treat with estrogen only HRT Titrate dose
against symptoms Benefits >> risks generally No increased
risk breast cancer (WHI study) No decreased risk bowel cancer
Slide 54
Ten tips to treating the menopause 5) Starting HRT If still
menstruating, give sequential HRT If stopped menstruating, give
continuous combined HRT Titrate dose Older women need a lower dose,
younger women need a higher dose
Slide 55
Ten tips to treating the menopause 6) Stopping HRT Dont put an
arbitrary time limit on HRT Aim for lowest effective dose Stop HRT
slowly by gradually reducing dose Dont be worried about restarting
if bothersome symptoms return
Slide 56
Ten tips to treating the menopause 7) Premature menopause (
risks in younger women Younger women need a higher dose Treat until
51, and then consider whether to continue COC or HRT in younger
women both effective
Slide 57
Ten tips to treating the menopause 8) Mirena and HRT Provides
adequate progestogen for HRT, Licensed for 4 years duration Most
likely to give bleed free HRT at any age. Titrate dose of estrogen
to symptom relief
Slide 58
Ten tips to treating the menopause 9) Non- hormonal treatments
for menopausal symptoms Behavioural Red clover Black Cohosh
SSRI/SNRI/Clonidine Acupuncture/Yoga/exercise Vaginal lubricants
silicone based
Slide 59
Ten tips to treating the menopause 10) Local (vaginal) HRT
Treat for Vaginal dryness/soreness Recurrent UTIs Sensory urinary
symptoms (frequency, urgency) At recommended doses, (treatment
twice weekly), can be continued as long as needed, without checks
Aim for lowest effective dose for long term treatment.