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Keeping the right patients away from hospital

Learn about conservative and surgical treatments for prolapse and urinary incontinence, and when to refer patients to specialists. Save time and money with proper diagnosis and management.

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Keeping the right patients away from hospital

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  1. Keeping the right patients away from hospital Richard Foon Consultant Obstetrician & Gynaecologist Royal Shrewsbury and Telford NHS Trust

  2. Department • Consultants • Other doctors • Continence nurse advisors • Physiotherapists • Urodynamics Team

  3. Uro - gynae - cology • Prolapse • Stress incontinence • Overactive bladder

  4. Prolapse Symptomatic Asymptomatic – no treatment needed Conservative Treatment If stage 1 Pessary Surgery If surgery fails Pessary Mesh

  5. Treatment of Prolapse • Reassure (Conservative, PFMT) • Ring (Pessaries) • Repair (Surgery)

  6. Prolapse staging

  7. Definitions • Urinary incontinence (symptom): complaint of involuntary loss of urine • Stress (urinary) incontinence: complaint of involuntary loss of urine on effort or physical exertion (e.g. sporting activities), or on sneezing or coughing • Urgency (urinary) incontinence: complaint of involuntary loss of urine associated with urgency

  8. Cured – Up to 50% Stress Incontinence – History, Exam etc Physiotherapy Not cured - Urodynamics Medical tx Urodynamic stress incontinence Macroplastique Surgery Tapes

  9. Costs (based on 100 patients) Savings/Cost Avoidance = £43,008 Personal communication R Freeman 2012

  10. UUI Conservative Treatment Behaviour Modification (Continence advisor) Bladder Re-training Fluid management Pelvic Floor Muscle Training (Physiotherapist) Better supervised’ Compliance Anti-muscarinic drugs Various Preparations Compliance

  11. Anticholinergic drugs Oxybutynin Tolterodine Trospium chloride Solifenacin Fesoterodine Darifenacin

  12. Mirabegron • Mirabegron – A new class of OAB treatment • A first in class β3-adrenoceptor agonist1 • Mirabegron works differently to antimuscarinics1,2 • Gras J. Drugs of Today 2012;48(1):25–32. • Betmiga Summary of Product Characteristics, December 2012. Date of preparation: February 2013. BET13018UK

  13. Special warnings and precautions Use with caution : • autonomic neuropathy • hiatus hernia • clinically significant bladder outflow obstruction • severe constipation • narrow-angle glaucoma; • gastrointestinal obstructive disorders • gastro-oesophageal reflux

  14. Voiding dysfunction • Post void residual - > 30 % of functional bladder capacity • Bladder scan- within 1 minute of void • Residual up to 50 mls • Iatrogenic : Radical pelvic surgery/TVT • Pelvic organ prolapse ( 33% stage 3/4) • Urethral strictures

  15. Who to refer ? • Failed anticholinergics x 2 • Unable to take anticholinergics ( eg: closed angle glaucoma) • Suspicion of other pathology ( Pelvic masses , neurological causes, retention) • Haematuria • Some iatrogenic causes

  16. Who to refer • microscopic haematuria in women aged 50 years and older visible haematuria • recurrent or persisting UTI associated with haematuria in women aged 40 years and older • suspected malignant mass arising from the urinary tract.

  17. Who to refer ? • suspected urogenital fistulae • previous continence surgery • previous pelvic cancer surgery • previous pelvic radiation therapy

  18. Who to refer ? • persisting bladder or urethral pain • clinically benign pelvic masses • associated faecal incontinence • suspected neurological disease • symptoms of voiding difficulty

  19. Take home message • Only treat SYMPTOMATIC prolapse • Physiotherapy • Rule out other causes of overactive bladder symptoms • Frequency / volume charts • Anticholinergics

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