The Diagnosis and Management of Incontinence

The Diagnosis and Management of Urinary Incontinence Mr C Dawson MS FRCS Consultant Urologist Edith Cavell Hospital, Peterborough Cromwell Clinic, Huntingdon What this talk is about Why Incontinence is an important problem How to diagnose and manage most types of

incontinence Case presentations Why Incontinence is important Major health issue that affects an estimated 10 million women worldwide Approximately 50% of all nursing home residents, and 15-30% of women over age 65 suffer from incontinence 50% of all women over age 18 years have mild

stress incontinence Prevalence of Unstable Bladder The average PCG (population ~ 100,000) will have over 5,600 people with urinary incontinence.1 One-third of residents in residential homes and two-thirds of residents in nursing homes suffer from urinary incontinence.2 Exact prevalence not known because often

concealed by sufferers 1 The Continence Foundation, Incontinence a Challenge & an Opportunity for Primary Care 2. DoH Guidelines, Good Practice in continence Services Related health problems Incontinence is a risk factor for: falls (26% increased risk) and fractures (34% increased risk) admission to hospital (1.3-1.5-fold risk) or

nursing facility (2-3.2-fold risk) Relationship to age Risk of developing incontinence increases with age1 10% age 45-49 years 20% age 60-64 years 32% age 70-74 years 1. Sifo Research & Consulting, Pharmacia & Upjohn 1998

Prevalence of incontinence by age 18 16 16.8% 15.4%

14 13.3% 12 10.9% Percentage

10 8 6 5.4% 4

2 2% 0 30-49 50-59 Age

1. Brocklehurst JC. Br Med J 1993;306:832-4 2. MORI Social Research Survey, August 1998 Men Women >60 The Cost of Unstable Bladder

Diagnostic evaluation (blood tests/urodynamics/ urine) Treatment (e.g. drug therapy/bladder retraining) Rehabilitation Incontinence pads/catheters Secondary consequences, e.g. skin irritation Admission to residential/nursing home Estimating the cost to the NHS England only 1988

Total cost 000 Drugs 22,732 Appliances

58,612 Containment products 69,000 Staff costs and direct overheads* 189,926

Surgery* 13,325 MINIMUM TOTAL 353,595 *This estimate makes no allowance for overheads beyond direct employment costs e.g. for the appropriate shares of the cost of premises and of ancillary staff

The Continence Foundation. Making the Case for an Integrated Continence Service. 2000 Cost of containment products in the U.K. in M Costs 1992 - 2001 250 200

150 100 50 0 1992 1996

Euromonitor. World Survey of Incontinence Products 1997. Euromonitor. London 2001 Estimated Impact of Urinary Incontinence on Quality of Life

Distress Embarrassment Inconvenience Threat to self esteem Loss of personal control Desire for normalisation

Kobelt G et al BJU International 1999; 83:583-90 015 Impact of Urinary Incontinence on Quality of Life Introduction of coping techniques1,2

Avoiding social interaction Toilet mapping Carrying spare clothing Avoiding long travel / journeys Can lead to social exclusion2 1. MORI Social Research Survey, August 1998 2. Brocklehurst JC, BMJ Vol 306 1993 Why you need to know about it

Patients often fail to seek help, and must therefore be supported when they do Prevailing attitude from patients - nothing can be done Many patients with mild symptoms can be greatly helped by simple investigations and treatment How to diagnose and Manage Incontinence

Recognise opportunity for diagnosis Take a full history Full examination Investigations

Management Why screen in Primary Care? Why screen for patients with unstable bladder? Prevalence Cost Government Initiatives Good Practice in Continence Services National Services Framework targets

047 Opportunities for screening

New Patient medical questionnaires New Patient medical examinations Routine cervical smears Family planning / Menopause clinics Patient leaflets / posters Practice audit

Health visitors / District nurses / Practice nurses Over 75 y.o. checks Nursing homes 052 Examination in Primary Care General - look for signs of systemic disease Weight / BMI Abdominal examination

Palpable abdominal or pelvic mass / bladder Pelvic examination Atrophic changes in vulva / vagina Utero-vaginal prolapse Demonstrable incontinence on coughing Rectal examination Tone of sphincter, exclude faecal impaction/prostatic Brief neurological / mental state examination Diagnosis in Primary Care

Other investigations may be possible in primary care (but are more likely to require referral): Pad testing Urodynamics Measurement of urine flow Residual volume Subtracted cystometry Videocystourethrography (VCU) Cystoscopy

022 The Management of Incontinence Types of Incontinence Symptoms and Signs

Investigations Management Types of Incontinence Anatomic or Genuine urinary stress incontinence Urge Incontinence Mixed False (Overflow) Incontinence Neuropathic Incontinence

Congenital Post-traumatic or iatrogenic Fistula Types of Incontinence Cough & Leak Small Volume

Frequency Nocturia Urgency Stress and Urge Incontinence Stress Mixed

Frequency Urgency Nocturia Urge Incontinenc e Urge Treat as detrusor instability (unstable bladder)

(urinalysis & physical examination normal) Adapted from: P Hilton, SL Stanton, BMJ, Vol 282, 1981 Incontinence in males Stress 8% Mixed

19% Urge 73% Hampel et al. Urology 1997; 50 (suppl 6A):4-14 Incontinence in females Urge

22% Mixed 29% Hampel et al. Urology 1997; 50 (suppl 6A):4-14 Stress 49%

Genuine Stress Incontinence (GSI) Cause Hypermobility of the vesico-urethral junction owing to pelvic floor weakness Symptoms and Signs

Leakage of urine in response to any physical activity - e.g. coughing, sneezing, bending down, exercise Genuine Stress Incontinence (GSI) Diagnosis

Management Incontinence may be demonstrable on examination. Urodynamics (VCMG) will confirm

Pads Weight Loss Pelvic Floor Exercises Surgery (Colposuspension, endoscopic bladder neck suspension) Urge Incontinence (UI) Cause

Detrusor instability with a normal sphincter, normal anatomy, and no neuropathy Symptoms and Signs

Leakage occurs due to unstable bladder contraction (NB - can be precipitated by cough and therefore mimic GSI) Usual symptoms of urgency, and frequency with or without urge incontinence

Unstable Bladder Symptoms Frequency is defined as 8 or more voids in 24 hrs.1 Urgency is a sudden, strong desire to void. 2 Urge incontinence is a wetting episode preceded by the sensation of urgency.2 1. Fast Facts - Continence 2000, Shah & Leach 2. Hampel C et al, BJU International (1999), 83, Suppl . 2., 10-15.

Urge Incontinence (UI) Diagnosis Management History is suggestive. Examination to rule out other factors. Urodynamics (VCMG) will confirm

Lifestyle changes Anticholinergic medication is first line therapy (NB warn patient about side effects) Clam Ileocystoplasty Modification of behaviour Set realistic expectations for the outcome of treatment. Log improvement in a diary Bladder retraining:

Re-educating the bladder to hold larger amounts of urine by gradually increasing the time between voids. Avoid caffeine and alcohol Reduce fluid intake Improve mobility and access to toilets Fast Facts, Urinary Continence,2000, Shah & Leach Pharmacological treatment of

unstable bladder includes: Antimuscarinic drugs: The most widely used in the U.K. Oxybutynin (Ditropan) Tolterodine (Detrusitol) Propiverine (Detrunorm) Antispasmodic drugs: Flavoxate Tricyclic antidepressants Oestrogens

1. British National Formulary No. 41. March 2001 2. Chapple et al, BJU 1990;66,491-494 3. MIMS August 2001 Surgery

Cystodistension Clam ileocystoplasty Suspension/sling techniques Injectable therapy 1. Fast Facts, Urinary Continence, 2000, Shah & Leach 2. Bidmead J, Cardozo L. Lancet 2000;355:2183-4 Clam Ileocystoplasty

Mixed Incontinence Many women will have both GSI and UI The management of these conditions is very different Accurate Assessment is important Aid to Diagnosis Neuropathic Incontinence

Incontinence in the presence of a demonstrable neuropathy Incontinence can be active (detrusor hyperreflexia), or passive (atony of sphincter), or a combination of the two Congenital Incontinence

Ectopic ureters Epispadias Exstrophy Cloacal malformation Specialist Opinion will be required in all cases Overflow Incontinence Usually the result of obstructive or

neuropathic lesion Commonly seen in men with BPH Often no preceding symptoms Examination vital to detect over full bladder Confirm with portable USS (large +++ residue) Needs referral to Urologist Traumatic Incontinence Associated with

Pelvic Fracture Sphincter damage post-TURP (note this is not GSI as sphincter is intact in GSI) Fistula Can be ureteral, vesical, or urethral Usually iatrogenic, after pelvic or vaginal surgery Needs specialist opinion and surgical repair Case Presentations

Case 1 Case 1 - answer Case 2 Case 2 - answer Case 3

Case 3 - answer Case 4 Case 4 - answer Case 5 Case 5 - answer

Case 6 Case 6 - answer Case 7 Case 7 - answer Case 8

Case 8 - answer Case 9 Case 9 - answer Case 10 Case 10 - answer

Case 11 Case 11 - answer Case 12 Case 12 - answer

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