Female U rinary Incontinence; Tips for Taming the Tinkles

1. Female Urinary Incontinence; Tips for Taming the Tinkles Felecia Fick, CRTT, PA-C

2. Disclosures • None

3. Objectives • Describe the evaluation of patients with urinary incontinence • Discuss how to diagnose different types of urinary incontinence • List treatment considerations for different types of urinary incontinence • Describe when to refer patients with urinary incontinence

4. Normal Micturition Cycle http://excellence.dxu.com/US,%20Normal%20Micturition%20Cycle.htm

5. What is normal? • Diurnal frequency- 8 voids • Nocturia- 0-1 void • Bladder capacity- 300-800cc • Normal voids- 300-500cc • Daily fluid intake 60-70 ounces

6. What is urinary incontinence? • Any involuntary loss of urine (International Continence Society/ICS and American Urological Association/AUA) • The symptom is the patient’s complaint • The sign is the objective demonstration of urine loss • Loss of bladder control (Mayo Clinic)

7. Prevalence • At least 50% of patients do not report urinary incontinence[5] • 25-51% of the population • Around 13 million in the United States [6,7] • More commonly seen caucasians,[4] multiple childbirths [10], aging [8], living in a nursing home [9]

8. Types of urinary incontinence • Stress • Urge • Mixed • Overflow • Functional • Neurogenic • Transient

9. Stress Incontinence • Involuntary loss of urine occurring when the intravesical pressure exceeds the maximum urethral pressure in the absence of a detrusor contraction (ICS) • Loss of urine with exertion -coughing, sneezing • Risk factors- pregnancy, vaginal deliveries, heredity, obesity • Norton’s test

10. Urge incontinence (Overactive Bladder) • Involuntary loss of urine associated with a strong desire to void/urgency (ICS) • Risk factors- aging, obesity, genetics, though usually idiopathic • ***Urinary tract infection

11. Mixed incontinence • Combination of stress AND urinary urge incontinence

12. Overflow incontinence • Bladder is not emptying and overflows • Frequent small urinations • Constant dribbling • Causes- • Weak detrusor contraction (neurological) • Outlet obstruction (pelvic prolapse, surgical procedures)

13. Functional incontinence • Incontinence due to a physical or cognitive impairment in the setting of a normal functioning urinary tract • Causes- • Mobility- (arthritis, orthopedic surgery) • Cognition- (Alzheimer's disease)

14. Neurogenic Bladders (incontinence) • Incontinence due to a neurogenic cause • Examples- (multiple sclerosis, spinal cord injuries, parkinsons, stroke) • May present as urge, stress, overflow, or retention • Requires a subspecialty appointment with a neurourologist so refer them

15. Transient incontinence • Temporary incontinence • Occurs in 33% of community dwelling elderly and 50% of acutely hospitalized patients • Secondary to “DIAPPERS” • D elirium • I nfection • A trophic vaginitis • P harmacological • P sychological • E ndocrine • R estricted mobility • S tool impaction [1,2,3]

16. Don’t ask, don’t tell-patient perspective • Patient embarrassment • Belief that symptoms are normal • Belief that symptoms will subside • Patient is unaware of treatment options or that treatment will be successful • Afraid of invasive, costly procedures - specifically the CATHETER….

17. Reasons incontinence is not addressed from a provider perspective • Many other important symptoms take precedence • Perception that patient is not bothered • Unaware of the significant impact on the patient’s quality of life • Unaware of treatment options or positive benefit of treatment

18. Reasons to address incontinence • Quality of life improvement • Morbidity and Mortality • Cost

19. Quality of Life

20. Morbidity and Mortality • Infections • UTIs, urosepsis, candida, cellulitis, pressure ulcers • Falls and fractures • Sleep deprivation • Psychological Impact • Poor self-esteem, depression, social withdrawal, sexual dysfunction • Caregiver burden [11,13,20]

21. Cost • Billions! • $20 billion in 2000 for total urinary incontinence costs to society [14] • 56 percent consequence costs (i.e., nursing home admissions) and loss of productivity [15,16] • $65.9B in 2007 for OAB • Projected $76.2B- 2015 • $82.6B-2020[17]

22. Patient evaluation • History • Questionnaires • Voiding Diary • Physical exam • Additional testing - urines - post void residual - urodynamics test - cystoscopy

23. History "Whatever you do, just don't get her startedon her bladder control problem."

24. Patient history • Review Questionnaire (UDI=urogenital distress inventory, IIQ=incontinence impact questionnarie…) • OBGYN • - number of pregnancies • - delivery method (vaginal, cesarean) • - instruments used (forceps, suction) • - degree of tearing, episiotomy • Pelvic Surgery

25. Patient history • Storage symptoms • Urgency • Frequency • Nocturia • Incontinence • Pain • Voiding symptoms • Hesitancy • Weak slow stream • Incomplete emptying • Post void dribbling • Pain Bladder symptoms (LUTS=lower urinary tract symptoms)

26. Bladder diary

27. Patient history “Incontinence” • When do you leak urine? What triggers your leakage episodes? • How often does it happen? • Do you wear pads? What kind of pad? How many per day? Are they soaked or damp?

28. Patient history • Vaginal symptoms • Itching, dryness, burning, discharge, bleeding, infection, history of skin conditions such as atrophic vaginitis or lichen sclerosus • Can be seen with pelvic prolapse and/or Incontinence

29. Patient history • Sexual history • Sexually active or not • Dyspareunia • Penetration, movement, orgasm, anorgasmic • Vaginal dryness-lubricants used • Post coital bleeding • ?sexually transmitted infection • Abuse

30. Patient history • Bowel symptoms • Constipation • Fecal incontinence • Splinting • Incomplete emptying

31. Patient history • Neurological • Pulmonary • Medical Diagnosis • Physical Mobility • Mental Status including psychiatric history • Obesity

32. Patient history • Medication review-diuretics, lithium, etc.. • Social • Smoking, alcohol, recreational drugs • Family history Gynecological, urological, colorectal malignancy

33. Physical Exam • General • Abdominal /Back(scars, masses, CVA tenderness on the back) • Urologic/gynecologic • Visual inspection • Skin conditions, rashes, atrophy, vaginal discharge • Perineal sensation, reflexes (soft touch/sharp) • Cough stress test • Kegels or pelvic floor myalgia • Prolapse • Masses-(bartholins, urethral, skenes, diverticulum, bimanual, rectal exam included in this evaluation)

34. Kegels • Squeezing and releasing the pelvic floor muscles which includes the vagina, urethra, rectum. • Same muscle used to stop the urinary stream. • Graded as absent, weak, moderate, strong. • Can be taught through pelvic floor physical therapy. • Used as a treatment option for urinary incontinence.

35. Squirting Sue • 40 yo c/o urinary incontinence only with running (no other urogynecological symptoms) • G4, P4 (vaginal, forceps with first 2, 3rd degree tearing with 3rd, largest birth weight 10 lbs) • BMI 22 • PMH/PSH-Healthy. No surgeries. • Medications/allergies-None. • Bladder diary, urines, post void residual-normal • Physical exam is normal with strong kegels.

36. Squirting Sue What is her diagnosis? • Transient incontinence • Overflow incontinence • Urge incontinence • Stress incontinence • Mixed incontinence

37. Squirting Sue Answer • Transient incontinence • Overflow incontinence • Urge incontinence • Stress incontinence • Mixed incontinence

38. Squirting Sue First LineTreatment • 1) Urethral insert (Femsoft) • 2) Pessary • 3) Kegels on her own • 4) Pelvic floor physical therapy/biofeedback • 5) Surgery • 6) Tell her to wear a pad

39. All are potential options, depending on how aggressive the patient wants to be with treatment

40. Squirting Sue First LineTreatment • 1) Urethral insert (Femsoft) • 2) Pessary • 3) Kegels on her own • 4) Pelvic floor physical therapy/biofeedback • 5) Surgery • 6) Tell her to wear a pad

41. Answer • 1) Urethral insert (Femsoft)

42. Urgency Ursula • 70 yo c/o urinary incontinence with a strong urge, urgency, frequency. No incontinence with cough or stress manuevers. • G0. • PMH/PSH-Healthy. No surgeries. BMI 30. • Medications/allergies-None. • Labs-Urines and post void residual are normal.

43. Urgency Ursula’s Physical Exam

44. Urgency Ursula’s Physical Exam

45. Urgency Ursula’s Physical Exam • No prolapse or incontinence. • Weak kegels. • Otherwise, unremarkable.

46. Bladder diary

47. Bladder diary

48. Bladder diary

49. Bladder diary

50. Urgency Ursula • What is her diagnosis? • 1) Stress incontinence • 2) Urge incontinence • 3) Mixed incontinence and atrophic vaginitis • 4) Overflow incontinence • 5) Urge incontinence and atrophic vaginitis