The Problem Bladder: UTI, the Unstable bladder and Mixed Incontinence Stephen Jeffery/Pieter Kruger Groote Schuur Hospital UCT Private Academic Hospital

How do you define happiness? At age 4Not wetting your bed At age 10Having friends At age 18Having a driver’s licence At age 21Having sex At age 30Having money At age 65Having money At age 75Having sex At age 80Having a driver’s licence At age 85Having friends At age 90Not wetting your bed

Incontinence: Classification Urethral Stress incontinence Stress incontinence Overactive (unstable) bladder Overactive (unstable) bladder Mixed incontinence Mixed incontinence Voiding dysfunction Voiding dysfunction Congenital Congenital Functional FunctionalExtra-urethral Congenital Congenital Fistula Fistula

Incontinence: Classification Urethral Stress incontinence Stress incontinence Overactive (unstable) bladder Overactive (unstable) bladder Mixed incontinence Mixed incontinence Voiding dysfunction Voiding dysfunction Congenital Congenital Functional FunctionalExtra-urethral Congenital Congenital Fistula Fistula

Stress 49% 2 Urge 22% 2 Mixed 29% 2

Overactive Bladder Symptom syndrome consisting of urgency, with or without urge incontinence, usually with frequency and nocturia, in the absence of proven infection or other obvious pathology

Urgency Key symptom Sudden compelling desire to void that is difficult to defer

Millions are Suffering in Silence Austin et al. Western European Market & Media Fact 2001; IMS Data 2001 Milsom I et al. BJU Int. 2001;87: Estimated 49 million people in Europe aged >40 suffer from OAB Untreated OAB Sufferers Treated OAB Sufferers Estimated 293 million people >40 years old in Europe 44 million out of 49 million OAB sufferers in Europe are currently not being treated

Impact of OAB 30% increase in falls (Brown et al) Increase in stress and depression (Kobelt et al) Greater impact than Diabetes on QOL (Samuelson) Annual cost 3.98 Billion Euros (Germany) 3% of women change jobs due to OAB (Diokno)

What about Stress Incontinence? Stress incontinence is an involuntary loss of urine that occurs during physical activity, such as coughing, sneezing, laughing, or exercise

Clinical approach to the incontinent woman

Approach Important symptoms – Nocturia – Frequency – Urgency / urgency incontinence – Stress incontinence – Significant bothersome prolapse

Approach Red flag symptoms – Voiding difficulties – Haematuria – Severe bladder pain

Approach General Medical History – Multiple sclerosis – Parkinsons – Stroke

Approach Surgical History – Previous incontinence surgery – Previous vaginal surgery

Medications That May Cause Incontinence Diuretics Antidepressants Antihypertensives Hypnotics Analgesics Narcotics Sedatives OTC sleep aids and cold remedies

Approach Assess for pelvic floor dysfunction Look for leakage on coughing Urogenital prolapse Atrophy

Approach Assess for pelvic floor dysfunction Faecal Urgency Faecal Incontinence Defaecatory difficulty

Aims of Investigation Exclude undelying organ specific related or unrelated conditions that would require intervention Assess the level of bother and desire for intervention Institute empiric or disease specific therapy Prompt appropriate referral for more complex testing

Urinalysis Pyuria 60% of women with stable bladder will have DO Glycosuria DM – Peripheral autonomic neurop, UTI Haematuria Urothelial Ca

Post Void Residual Use a catheter Can use an ultrasound machine

Diary Frequency episodes Intake & output Bladder capacity Exclude 24 h polyuria (DI) & nocturnal polyuria

Standard Therapy Options for the Overactive Bladder Behaviour Modification Anticholinergics

Behavioural Modification Education Delayed voiding Timed voiding Reinforcement Pelvic floor exercises

Immediate release Oxybutynin Ditropan® Lendrito® Merck-Oxybutynin Chloride® Sandoz-Oxybutymin HCl ® Urihexal® Dose 2.5mg BD to 5mg qid Anticholinergics availalble in South Africa

Oxybutynin SR Lyrinel® Dose 5,10, 15 or 20mg per day Tolterodine Detrusitol SR® Dose 2 or 4mg per day Trospium Uricon® Dose 20mg BD Anticholinergics availalble in South Africa

Propiverine Detrunorm® Dose 15 mg 1–3 times daily to 15 mg 4 times daily Darifenacin Enablex® Dose 7.5 or 15mg per day Solifenacin Vesicare® Dose 5 or 10mg per day Anticholinergics availalble in South Africa

Persistence on Specific Medications for OAB Based on Prescription Data Chui M, et al. Value in Health. 2004;7:366. Percent Months

100% Why do patients stop taking antimuscarinic therapy? %10%20%30%40%50%60%70%80%90% Insufficient efficacy Intolerable side effects Dosing convenience Other reasons Female ≤55 Years of Age Female >55 Years of Age Male In Employment/Activity Working Retired/Unemployment OAB Dry Pure UUI Mixed UI Reference: Global Market Research Study (Yamanouchi Pharma Ltd, December 2003:n=736). International web survey

Options?? When Anticholinergics Fail

Botulinum Toxin

Administration

12 weekly sessions of 30mins Success expected after 6-8 session Tapering protocol – once every 2-3 weeks PTNS Posterior Tibial Nerve Stimulation

When to refer Mixed incontinence with obvious stress component High residual Failure to respond to anticholinergics Haematuria Painful bladder

Managing Stress Incontinence

Colposuspension

Tension free vaginal Tape (TVT)

Retropubic Tape

Pubic Symphysis TVT Needle Bowel Anterior Abdominal Wall

Transobturator Tape

Continence rates Both between 85 and 90%

Complications Transobturator and Retropubic –Voiding dysfunction –Worsening in Overactive Bladder Retropubic –Bladder / bowel injury –Haematoma Transoburator –Groin pain

Bottom line about stress incontinence surgery Relatively good outcomes Refer to a competent surgeon Be aware of complications

Recurrent UTI More than 3 UTI in one year

Recurrent UTI Causes Genetic Atrophy Foreign body in bladder High urinary residual Prolapse Stroke

Recurrent UTI Work up Residual Ultrasound KUB Think about referring for cystoscopy

Recurrent UTI Treatment Empty bladder before and after sex Cranberry juice/ tabs Premarin cream Address high urinary residual Daily prophylactic antibiotics