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AN APPROACH TO URINARY INCONTINENCE IN PRIMARY CARE

AN APPROACH TO URINARY INCONTINENCE IN PRIMARY CARE . Len Lotimer Annual Update Day in Obstetrics and Gynecology Wednesday October 22, 2008 Raed Sayed Ahmed MBChB,FRCS(c ). OBJECTIVES. Reco g nize the impact of u rinary incontinence. List types of urinary incontinence.

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AN APPROACH TO URINARY INCONTINENCE IN PRIMARY CARE

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  1. AN APPROACH TO URINARY INCONTINENCE IN PRIMARY CARE Len Lotimer Annual Update Day in Obstetrics and Gynecology Wednesday October 22, 2008 Raed Sayed Ahmed MBChB,FRCS(c)

  2. OBJECTIVES • Recognize the impact of urinary incontinence. • List types of urinary incontinence. • Outline management options.

  3. BACKGROUND • Urinary incontinence affects 10–70% of women living in a community setting and up to 50% of nursing home residents1. • Prevalence of incontinence appears to increase gradually during young adult life, has a broad peak around middle age, and then steadily increases in the elderly2. 1. Abrams P, Cardozo L, Khoury S, Wein A, editors.Incontinence. 2nd ed. Plymouth, UK: Health Publication Ltd; 2002. 2. Hannestad YS, Rortveit G, Sandvik H, Hunskaar S. Acommunity-based epidemiological survey of female urinary incontinence: the Norwegian EPINCONT study. Epidemiology of Incontinence in the County of Nord-Trondelag. J Clin Epidemiol 2000;53:1150–7.

  4. QUALITY OF LIFE ISSUES • Impacts negatively on one’s physical, psychological, sexual, social and overall quality of life. • More likely to suffer from depression than their continent peers1. • Urinary incontinence, Alzheimer’s disease, and stroke are the 3 chronic health conditions that most adversely affect an individual’s health-related quality of life2. 1-Vigod SM, Stewart DE, Major Depression in Female Urinary Incontinence Psychosomatics 47:147-151, April 2006 2-Wallace SA, Roe B, Williams K, Palmer M. Bladder training for urinary incontinence in adults.Cochrane Database Syst Rev 2004; Issue 1(Art. No.: CD001308. DOI: 10.1002/14651858.CD001308.pub2)

  5. TYPES OF INCONTINENCE • Stress Urinary Incontinence (SUI): Leaking of urine with coughing, sneezing, straining, exercise or any other type of exertion. 50% of individuals withincontinence have SUI.

  6. TYPES OF INCONTINENCE • Urge Incontinence (UI): Leaking of urine associated with the sudden uncontrollable urge to empty the bladder. The urge to empty the bladder cannot be delayed and leakage occurs. UI is a key symptom of the overactive bladder syndrome.

  7. TYPES OF INCONTINENCE • Overflow incontinence (OI) is constant leaking or dribbling from a full bladder. • Mixed incontinence (MI) is a combination of stress and urge incontinence.

  8. MANAGEMENT OF URINARY INCONTINENCE History: • Leaking with L/C/S or U • Urgency/Frequency/Nocturia • Prev. therapies • PMH • Past Surgical History • Medications

  9. MANAGEMENT OF URINARY INCONTINENCE Physical: • Cough test • Speculum/Bimanual. Investigations: • Urine analysis and Culture. • Voiding diary

  10. MANAGEMENT OF URINARY INCONTINENCE STRESS • Conservative/Life style • Kegels • Pessaries • Surgery URGE • Conservative/Life style • Bladder protocol • Kegels • Anticholinergics

  11. DIFFERENTIAL DIAGNOSIS Differential Diagnosis of Urinary Incontinence Genitourinary etiology 1-Filling and storage disorders Urodynamic stress incontinence Detrusoroveractivity (idiopathic) Detrusoroveractivity (neurogenic) Mixed types 2-Fistula Vesical Ureteral Urethral 3-Congenital Ectopic ureter Epispadias Nongenitourinary etiology 4-Functional Neurologic Cognitive Psychologic Physical impairment 5-Environmental 6-Pharmacologic 7-Metabolic ACOG Practice Bulletin No. 63 Urinary Incontinence in Women

  12. PREDICTING TYPE OF INCONTINENCE FROM SYMPTOMS • Urgency is accepted as both a sensitive and specific symptom for OAB. • Leakage with stress maneuvers is highly sensitive for stress urinary incontinence.

  13. WHEN TO REFER? • Previous continence or prolapse surgery. • Moderate to severe prolapse. • Objective clinical findings do not correlate with symptoms. • Trials of therapy fails to improve symptoms. • Sterile hematuriaor pyuria. • Irritative voiding symptoms, such as frequency, urgency, and urge incontinence, in the absence of any reversible causes. • Bladder pain. • Recurrent cystitis. • Suburethralmass.

  14. BEHAVIOURAL TREATMENTS • Evidence that conservative management can help control urinary incontinence including: • Behaviour training • Education • Scheduled voiding • Positive reinforcement • Pelvic muscle exercises with various techniques 1. 1-Wallace SA, Roe B, Williams K, Palmer M. Bladder training for urinary incontinence in adults. Cochrane Database Syst Rev 2004; Issue 1(Art. No.: CD001308. DOI: 10.1002/14651858.CD001308.pub2)

  15. BEHAVIOURAL TREATMENTS Healthy bladder behaviours: • Caffeine/alcohol (coffee, tea, carbonated drinks). • Non-caffeinated fluids (1.5-2.0 litres) per day. • Take your time voiding. • Healthy weight. • Don’t smoke. • Avoid constipation.

  16. PELVIC FLOOR RETRAINING • Requires education. • Cochrane review1 recommended that PFMT be included in first-line conservative management. • Effect greater in younger women (40’s and 50’s) with SUI alone, who participate in a supervised PFMT program for at least three months. 1-Hay-Smith EJC,Dumoulin C. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database of Systematic Reviews 2006, Issue 1.

  17. VAGINAL WEIGHT • Evidence that weighted vaginal cones are better than no active treatment in women with SUI. • May be of similar effectiveness to PFMT and electrostimulation.

  18. ESTROGEN TREATMENT • No compelling, objective evidence. • May improve urogenital aging symptoms such a vaginal dryness and some sensory bladder symptoms.

  19. DRUG THERAPIES Types of drugs used to treat patients with overactive bladder (OAB): • Anticholinergic medications (e.g., oxybutynin, tolterodine, impramine, trospium): these reduce feelings of urgency and inhibits contraction of the detrusor muscle. • Tricyclic antidepressants (e.g., imipramine): these exert an anticholinergic effect by blocking norepinephrine or serotonin amine uptake. • Combined anticholinergics and smooth muscle relaxants (e.g., oxybutynin chloride).

  20. PESSARIES • The pessary presses on the urethra through the vaginal wall and holds up the bladder neck and uterus, if present. • It may also pinch the urethra closed to help retain urine in the bladder. • It is usually not necessary to remove the pessary to urinate. Normal bladder contractions can usually force urine out through the pinched-off urethra.

  21. RETROPUBIC SUSPENSION TECHNIQUE • Stress incontinence procedure. • Also called colposuspension or Burch procedure. • Stitches are placed on both sides of the urethra. • Provide a rigid backboard to the urethra. • Good long term efficacy.

  22. MID-URETHRAL SLING • Stress incontinence procedure. • Minimally-invasive procedure. • Highly effective. • Polypropylene mesh ribbon place under the urethra. • mesh is applied around the midurethra in order to hold it securely. • provides support without fixation of the bladder neck.

  23. SACRAL NERVE MODULATION (SNM) • A device is implanted to stimulate electrically the sacral nerves in an attempt to manage voiding conditions. • It is a reversible procedure, in that the device can be removed without permanent injury. • The role of SNM is to manage patients who have not been treated successfully with behaviour therapy, drug therapy, or external stimulation (for urgency incontinence).

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