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Female Urinary Incontinence

Female Urinary Incontinence. Pregnancy. Urinary Incontinence and Prolapse. Incontinence and prolapse commonly coexist But, they do not always share a common cause or a common treatment. Types of Urinary Incontinence:. Stress incontinence Urge incontinence Mixed

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Female Urinary Incontinence

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  1. Female Urinary Incontinence

  2. Pregnancy

  3. Urinary Incontinence and Prolapse • Incontinence and prolapse commonly coexist • But, • they do not always share a common cause • or a common treatment

  4. Types of Urinary Incontinence: • Stress incontinence • Urge incontinence • Mixed • Chronic urinary retention and overflow incontinence • Miscellaneous (UTI, dementia, fistulae)

  5. 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

  6. 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

  7. Frequency / Voiding chart • Keep chart for 3-7 days • Gives an idea of fluid intake • Useful in explaining to patient about changes to intake

  8. Advice about lifestyle factors • High or Low fluid intake (from intake/output fluid charts) • Weight loss if BMI > 30

  9. Increased Intra-abdominal Pressure: • Pregnancy • Pulmonary disease – smokers cough • Constipation/straining • Lifting – work and home • Exercise • Obesity

  10. 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)

  11. Pelvic Floor Exercises

  12. 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

  13. Drug treatment for urgency/OAB • oxybutinin OR • clarifenacin • solifenacin • tolterodine • trospium • different oxybutinin formulations

  14. Mixed incontinence • Treat whichever symptom predominates (what is your worst problem?)

  15. 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

  16. 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

  17. 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

  18. 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

  19. 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

  20. Surgery: • For stress incontinence • Tension-free vaginal tape – TVT • Burch coplosuspension • Anterior colporraphy, anterior repair • Bladder neck injections – Zuidex • For overactive bladder • Bladder distension, urethral dilatation • Botox injections to bladder wall • (Detrusor myectomy, clam enterocystoplasty)

  21. Surgical treatment for incontinence • Discussion • Benefits • Success rate • Associated improvements • Quality of life • Risks • Surgical • Development of overactive bladder • Quality of Life

  22. 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

  23. TVT – tension free vaginal tape

  24. TOT - Transobturator Tape

  25. Prolapse

  26. Prolapse • 4 options • Do nothing – if asymptomatic • Physiotherapy – if minor (stage 1) • Vaginal support pessaries – suit some • Surgery • Traditional vaginal repair • Newer meshes

  27. Menopause and HRT

  28. HRT, where are we now? • Up to 2002 – Widespread HRT use • 2002 Women’s 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

  29. 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

  30. 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

  31. Risk of Hip fracture – effects of E+P vs E alone E alone E+P

  32. Risk of invasive breast cancer – effects of E+P vs E alone E+P E alone

  33. Risk of Coloectal cancer – effects of E+P vs E alone E+P E alone

  34. Risk of coronary heart disease – effects of E+P vs E alone E+P E alone

  35. Risk of Stroke – effects of E+P vs E alone E+P E alone

  36. Hazard ratios from WHI trials Risk Possible risk/benefit Benefit

  37. 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

  38. What do we tell patients now?

  39. 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

  40. 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

  41. 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

  42. 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

  43. How long should a woman take HRT for?

  44. 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

  45. 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

  46. 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

  47. 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.

  48. 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 • Thrombosis Risk 2-3 / 10,000 per year Risk greatly with patch/gel (non oral) • Stroke Risk for older age group/hypertensive Dose related • CV disease Risk in older patients commencing HRT

  49. 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)

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