Female Urinary Incontinence
An overview in clinical presentation and management
Dr. Salwan Al-SalihiUroGynaecologist and Pelvic floor surgeon
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Learning Objectives:
• Understand the clinical background and presentation of different types of urinary incontinence.
• Outline the different steps in diagnosing and managing such cases.
• To develop a clinical algorithm with channels for referral and future follow up.
• Outline different management options and there prospects.
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Urinary incontinence
v Prevalence in Australia: Incontinence in women varies from 16.5% in 20-40 year olds to 31% in over 80 year olds.
v The prevalence increases with age; among women, it is 2 fold higher in the over 80 age group compared to 20-40 age group. (The Australian Commonwealth Department of Health and Aged Care)
v Up to 65% of those women recall that their symptoms began either during or shortly after childbirth.
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In 2010, the total financial cost of incontinence in Australia was an estimated $42.9 billion1
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Statement: vEpidemiologic evidence
supports an association between PFDs and pregnancy and childbirth and suggest that the overall impact of parity is substantial.
v Among parous women, it has been estimated that 50% of incontinence and 75% of prolapse can be attributed to pregnancy and childbirth.
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Types of Urinary Incontinence: vUrodynamic stress incontinence.
vDetrusor over activity.
vMixed.
vOverflow incontinence.
vTemporary (UTI).
vFunctional disorder (mobility, cognitive).
vExtra urethral (ectopic ureter or Fistula).
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Clinical evaluation:vPresenting Symptoms:
type :SI, UI, insensible leakage
onset, frequency, duration, severity.
vAssociated Symptoms:
Urinary frequency, nocturia
Dysuria, bladder pain, haematuria
Voiding dysfunction
Bowel symptoms: constipation, AI
Effect on sexual function7
Urge Incontinence
InternationalContinenceSociety(ICS)definitionof
overactivebladder1
Urgencywithorwithouturgeincontinence,generallyusuallywithincreasedfrequencyandnocturia
Componentsofoveractivebladder
UrgencyThecomplaintofasudden compellingdesiretopassurinethatisdifficult
todefer
UrgencyUrinaryIncontinence
Thecomplaintofinvoluntary lossof
urinethatisaccompaniedbyor
immediatelyprecededbyurgency
UrinaryFrequencyTheneedtovoid
morethan8timesina24-hour period
NocturiaThecomplaintof
havingtovoidmorethanoncepernight
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Differentialdiagnosisofsymptomssuggestiveofoveractivebladderinwomen1
Adaptedfrom:1.RosenbergMTetal.CleveClinJMed2007;74Suppl3:S21–9.
§ Urinary tract infection
§ Prolapse
§ Urethral obstruction
§ Atrophic vaginitis
§ Bladder cancer
§ Interstitial cystitis
§ Postsurgical incontinence
§ Diabetes
§ Congestive heart failure
§ Multiple sclerosis
§ Medications/diuretics
§ Neurogenic bladder
§ Recent pelvic surgery
§ Stress urinary incontinence9
Management of DOA:vLifestyle changes therapy.
vPhysiotherapy.
vPharmacological therapy.
vAnti-continence devices.
vAbsorbent products catheters.
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Lifestyle changes: vDietary: some foods and beverages are
thought to contribute to bladder leak (not been proven it may be reasonable to see if eliminating one or all of them helps):
vAlcohol. vCarbonated (+/- Caffeine).vCoffee and tea (+/- Caffeine).vCitrus juice and fruits.
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Pharmacotherapy
5 broad classes:vDecrease detrusor contractility
vIncrease urethral resistance
vDual effects
vReduce fluid out put (Minirin)
vNeurotoxins
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Pharmacological therapy:Decrease detrusor contractility:vOxybutynin (Ditropan)/(Oxytrol)
v Tolterodine (Detrusitol)v Solafenacin (Vesicare)vDarifenacin (Enablex)
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When to refer? And “Who” do you refer to?
v Failed conservative Management.
v Pain, Haematuria or recurrent UTIs (>or=3 in 6/12)
v Voiding difficulty.v Suspected fistula.v Neuropathic bladder.v Significant pelvic organ
prolapse.v Uncertain diagnosis.
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Indications for Urodynamics:① Failed to respond to empirical treatment.② Previous continence surgery.③ Prior to definitive continence procedure.④ Prior to prolapse repair accompanying stress incontinence.⑤ Symptoms suggesting of voiding difficulty.⑥ Presence of neurological disease.
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Aim of Uds:
1. Identify / eliminate detrusor overactivity (it influence treatment options).
2. Identify / eliminate voiding difficulty (complicate treatment outcome)
3. Confirm the presence of SI.
4. Identify the presence of prolapse and relation to the bladder dysfunction (Boney’s test)
5. Assess severity ( help triage patients).
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Other treatment for OAB:Botulinum neurotoxin
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Sacral nerve Modulation (for refractory Bladder over activity)
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Surgery for UI
Augmentation cystoplasty
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Stress IncontinencevIncontinence of urine when the intra-vesical pressure
exceeds the maximum urethral pressure in the absence of detrusor activity.
vPresents as: involuntary leakage on effort or exertion, or on sneezing or coughing.
vDuring Urodynamics: the involuntary leakage of urine during increased abdominal pressure, in the absence of a detrusor contraction.
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Stress incontinence:
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Stress incontinence:
Female stress urinary incontinence (SUI) is a common condition, with prevalence rates ranging from 12.8% to 46.0%.
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NOT A SOLUTION
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Treatment : Conservative
} Lifestyle changes : correct exacerbating factors} Physiotherapy◦ Bladder re-training◦ PFE / Kegel exercises
� 30-50% improvement with supervised physio 3/12� Less 1/3 may be unable to do PFE correctly even with
physio} Vaginal cones
� Pelvic floor contraction required to keep cone in position� 70% improvement, need life-long use to maintain
improvement} Vaginal oestrogen
◦ ↑ subjective outcome in SI, no change in objective loss
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Surgical treatment SI
1. Retro pubic urethropexy (Burch)
2. Suburethrtal slings (TVT,TVT-O et al)
3. Retropubic Rectus sheath sling (Pubovaginal Sling).
4. Periurethral Injection
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Burch colposuspension}Gold standard for many years (not now) !
Laparoscopic colposuspension:Long learning curve: 35-50 cases
No standardized techniqueSuture type, placement and number identical to open
Expensive procedure RCT’s : LB to be as effective as OB for USI
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TVT
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TVT : technique
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TVT : complications
} General : anaesth, DVT} Bleeding (recorded case of EIA
perforation)} Infection
} Bladder perforation, injury to urethra} Bowel injury (uncommon)
} Voiding dysfunction (long-term catheter 1%, need to divide tape)
} Mesh erosion
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TVT
} The gold standard procedure of USI} Simple, safe and minimally invasive} Short learning curve: 5-10 cases
} Standardized technique} Appropriate in many clinical situations
} Most efficient} Over 1,000,000 cases
} 14.5 years data available now
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Refinements:
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Transobturator tapes
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Refinements:
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Mini Tapes (Single Incision Slings)
MiniArc Precise Sling (AMS)
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Periurethral bulking agents
}Cure rate (defined as dry) at 12/12 = 48% (RCOG 2003)
}Success rate (improvement) = 76%}Pros: fewer voiding problems,
repeatable procedure and its an out patient’s procedure.
}Cons: expensive and less effective with repeat
} 7+ years data available now
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Periurethral bulking agents
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Bulking Agents
•Macroplastique: Bulkamid:
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Pregnancy after continence surgeryvThere is no consensus on management
of pregnancy and delivery in women who have undergone a surgical procedure for treatment of SUI.
vWhile many patients and clinicians assume that cesarean delivery is the only delivery option in these cases, this has not been established.
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Case 1
v61y.o womanv2 yrs of mixed SI + UI
vDaily leakage, wearing padsvNo previous surgery
vExamination:vAtrophic vagina
vModerate rectocelevHypermobile BNvDemonstrable SI
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Management
üMSU
ü Bladder diary
üUrodynamics
Options:
vConservative treatment
vCorrect predisposing factors
vPhysiotherapy PFE & BRT
vVaginal oestrogen
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Urodynamics:
vDetrusor overactivity
vModerate UD SI
vMUCP 57cmH20
vNormal voiding
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Treat OAB first if large component of UI
Anti-cholinergics
Exclude C/I * glaucoma
Start Ditropan 5mg BD
Discuss anti-cholinergic s/e
If unable to tolerate s/e, try Tolterodine 2mg BD
Review 2/1242
Persistent SI despite conservative treatment
Offer surgery
TVT
85% success for SI
Warn risk of worsening UI
Vaginal repair only if prolapse symptomatic
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Case 2
v75 y.o womanvRecurrent SI
vPH: Burch colposuspension, VR x2vWet all the time
vSlow voiding since Burch
vExaminationvFixed BN
vMarked SI demonstratedvNo prolapse
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Management
Bladder diary
Physiotherapy
Urodynamics:
vStable detrusor
vMarked UD SI
vMUCP 15cmH20
vBorderline VD
vVoided 390ml, flow rate 12ml/sec, RV 100ml
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Assessment
Gross SI
Fixed BN
Low MUCP
Suggests intrinsic sphincter deficiency
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Management
Surgery:
Transurethral bulking agent
Macroplastique / Bulkamid
Under LA if necessary
Avoid slings/ tapes if VD
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Thank you..
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