Lower Urinary Tract Problems in Women Ellie Stewart CNS Urogynaecology Guys and St Thomas NHS Foundation Trust

QOL and incontinence Incontinence has a massive impact on QOL Incontinence has a massive impact on QOL Under reporting due to embarrassment Under reporting due to embarrassment Often don’t seek help until problem is severe Often don’t seek help until problem is severe Male doctors, no time, unsympathetic, don’t understand Male doctors, no time, unsympathetic, don’t understand It affects: Relationships, work, friends, day to day activities, finances It affects: Relationships, work, friends, day to day activities, finances BUT…….Symptoms are easily improved with help and an understanding of the problem BUT…….Symptoms are easily improved with help and an understanding of the problem

Assessment Vital to ensure you are treating correctly. Vital to ensure you are treating correctly. Simple ‘must dos’ at initial assessment in community or hospital: Simple ‘must dos’ at initial assessment in community or hospital: Take history- Take history- symptoms, duration, cause, symptoms, duration, cause, Exclude UTI- urinalysis Exclude UTI- urinalysis Exclude constipation Exclude constipation Measure post void residual- ISC or bladder scan Measure post void residual- ISC or bladder scan Bladder diary- monitor input and output at least 3 days (NICE 2013) Bladder diary- monitor input and output at least 3 days (NICE 2013) Try and see what main problem is and advise Try and see what main problem is and advise Information leaflets on intranet Information leaflets on intranet Examine to assess pelvic floor tone or for prolapse- if feel confident to do so Examine to assess pelvic floor tone or for prolapse- if feel confident to do so Seek help Seek help

Onward referral Red flags: Red flags: Microscopic haematuria in women >50 years Microscopic haematuria in women >50 years Visible haematuria Visible haematuria Recurrent UTIs with haematuria in women >40 Recurrent UTIs with haematuria in women >40 Suspected malignant urinary tract mass Suspected malignant urinary tract mass Specialist service referral: Persisting bladder/ urethral pain Benign pelvic mass Faecal incontinence Neurological disease Voiding difficulties Urogenital fistulae Previous continence surgery Previous pelvic cancer surgery or radiotherapy

Types of Urinary Incontinence Stress urinary incontinence Stress urinary incontinence Overactive bladder Overactive bladder Urge incontinence Urge incontinence Overflow incontinence Overflow incontinence Bladder outlet obstruction Bladder outlet obstruction Functional incontinence Functional incontinence

Stress Incontinence When? Who? Symptoms.. When? Who? Symptoms.. Common in women following childbirth Common in women following childbirth Menopause Menopause Post hysterectomy Post hysterectomy Leakage when intra-abdominal pressure increases- cough, sneeze, laugh, run, jump Leakage when intra-abdominal pressure increases- cough, sneeze, laugh, run, jump Treatments Pelvic floor exercises Vaginal cones and electrical stimulation Weight loss, constipation prevention Surgery- TVT, colposuspension, peri- urethral injectables, sphincter surgery

Pelvic floor exercises Fast and slow twitch exercises Offer for at least 3 months as first line treatment How often? Lying sitting or standing? The ‘knack’ Squeezy app NICE 2013: 8 contractions x3 daily Pelvic Floor Muscles

WHAT ABOUT GADGETS?

BIOFEEDBACK DEVICES Not routinely used for women with OAB or in combination with pelvic floor exercises Consider in women who cant contract pelvic floor muscles- aids motivation and adherence

Surgical management Stress incontinence: Stress incontinence: TVT TVT TVTo TVTo Colposuspension Colposuspension Macroplastique Macroplastique

Medical management Stress Incontinence: Stress Incontinence: Duloxetine- not as a first line treatment, or second line- may offer if women prefer pharmacological treatment to surgical treatment Duloxetine- not as a first line treatment, or second line- may offer if women prefer pharmacological treatment to surgical treatment Counsel as to the side effects- nausea and vomiting Counsel as to the side effects- nausea and vomiting Wean off slowly as its an SSRI Wean off slowly as its an SSRI

Overactive bladder Symptoms: Symptoms: Frequency Frequency Urgency Urgency Urge incontinence Urge incontinence Nocturia Nocturia Treatments: Pelvic floor exercises Caffeine reduction Fluid advice- type, how much, when Bladder diary Bladder retraining Medications Botox

LIFESTYLE CHANGES Fluids May irritate the bladder: Caffeine (tea, coffee, green tea, hot chocolate) Caffeine (tea, coffee, green tea, hot chocolate) Artificial sweetener Artificial sweetener Fizzy drinks Fizzy drinks Tomatos Tomatos Citrus fruits and juices Citrus fruits and juices Blackcurrant juice Blackcurrant juice Alcohol Alcohol May not irritate the bladder: Water Water Fruit and herbal teas (avoid nettle and fennel) Fruit and herbal teas (avoid nettle and fennel) Milk Milk Diluted fruit juice Diluted fruit juice

Bladder retraining Bladder training aims to: Bladder training aims to: Increase bladder capacity Increase bladder capacity Reduce frequency of toilet visits Reduce frequency of toilet visits Increase the time between voids Increase the time between voids Lifestyle changes Lifestyle changes Learn urge suppression techniques- pressure sensor in big toes, sit on hard surface, contract pelvic floor muscle Learn urge suppression techniques- pressure sensor in big toes, sit on hard surface, contract pelvic floor muscle Should be tried for a minimum of 6 weeks before trying medications (NICE 2013) Should be tried for a minimum of 6 weeks before trying medications (NICE 2013)

Medical Management Overactive Bladder Overactive Bladder Antimuscarinics Antimuscarinics Oestrogens- vagifem, ovestin Oestrogens- vagifem, ovestin Betmiga- beta 3-adrenoceptor agonist Betmiga- beta 3-adrenoceptor agonist PTNS- percutaneous tibial nerve stimulation PTNS- percutaneous tibial nerve stimulation Botilium toxin A Botilium toxin A

Anticholinergics for OAB- how do they work? Block nerve impulses to the bladder which decreases the ability of the bladder muscle to contract Block nerve impulses to the bladder which decreases the ability of the bladder muscle to contract Can help the bladder hold on to more urine Can help the bladder hold on to more urine Most Common Side Effects as they are non selective: Most Common Side Effects as they are non selective: Dry mouth Dry mouth Constipation Constipation Blurred vision Blurred vision Tiredness Tiredness

What antimuscarinics should be used? First line: First line: Oxybutinin IR, tolterodine IR, darifenacin Oxybutinin IR, tolterodine IR, darifenacin Transdermal patch if unable to tolerate oral medications Transdermal patch if unable to tolerate oral medications Others available are: Others available are: Solifenacin, fesoterodine Solifenacin, fesoterodine

Mirabegron/ Betmiga Beta 3-adrenoceptor agonist Beta 3-adrenoceptor agonist Less dry mouth and constipation Less dry mouth and constipation Some patients experience tachycardia/ palpitations, keep an eye on BP Some patients experience tachycardia/ palpitations, keep an eye on BP Use once antimuscarinics tried and not successful or if experiencing intolerable dry mouth and constipation Use once antimuscarinics tried and not successful or if experiencing intolerable dry mouth and constipation Or in conjunction with vesicare- combination therapy Or in conjunction with vesicare- combination therapy

Vaginal Oestrogens Offer topical vaginal oestrogens in post menopausal women with vaginal atrophy Offer topical vaginal oestrogens in post menopausal women with vaginal atrophy Not to use systemic HRT Not to use systemic HRT Vagifem 10mcg Vagifem 10mcg Ovestin 0.1% Ovestin 0.1% Orthogynest 0.01% Orthogynest 0.01%

Vaginal Lubrications Replens vaginal moisturiser/ hylaofemme in those not suitable for oestrogens Replens vaginal moisturiser/ hylaofemme in those not suitable for oestrogens Sylk Sylk Yes- water and oil based Yes- water and oil based Senselle Senselle Pjur Pjur Moisturise vagina, don’t treat the dryness Moisturise vagina, don’t treat the dryness

Percutaneous Tibial Nerve Stimulation The use of PTNS is supported as a second line therapy 12 week course for half an hour each time Only to be used after MDT and failure of conservative mgm and the woman doesn’t want botox- NICE 2013

Botilium Toxin A After MDT review, for women with OAB caused by proven detrusor overactivity not responding to conservative treatments Short term management, lasts approx 9-12 months High risk of needing to intermittently catheterise- 1/3 of patients

Surgical management Overactive bladder: Overactive bladder: Sacral nerve stimulation- NICE shouldn’t be offered to treat OAB Sacral nerve stimulation- NICE shouldn’t be offered to treat OAB Augmentation cystoplasty Augmentation cystoplasty Urinary diversion Urinary diversion Detrusor myectomy Detrusor myectomy

Pessaries Small medical device inserted into the vagina to function as a supportive structure for the uterus and/or bladder and rectum. Small medical device inserted into the vagina to function as a supportive structure for the uterus and/or bladder and rectum. latex or silicone. latex or silicone. Comes in different shapes and sizes. Comes in different shapes and sizes. Needs to be replaced every 3 to 6 months. Needs to be replaced every 3 to 6 months. Some pessaries need to be removed, cleaned and reinserted every night- inflatoball, cube. Some pessaries need to be removed, cleaned and reinserted every night- inflatoball, cube. They do not stop the prolapse from worsening. They do not stop the prolapse from worsening. Not suitable for all types of prolapse Not suitable for all types of prolapse Use of oestrogen Use of oestrogen

Indications Pessaries are generally recommended as a conservative form of treatment for pelvic organ prolpse in women who are: Pessaries are generally recommended as a conservative form of treatment for pelvic organ prolpse in women who are: 1. Awaiting surgery 2. Pregnant or want to have more children in the future 3. Unable or choose not to undergo surgery.

Type of pessaries

Prolapse Types Anterior Compartment Anterior Compartment Posterior Compartment

Uterine Prolapse Uterine Prolapse Vault Prolpase

Minimum Standards for Continence Care 2014 To encourage improvements in standards of Continence care To encourage improvements in standards of Continence care Shows ideal structure of continence services Shows ideal structure of continence services Shows what training is required for those working in continence care Shows what training is required for those working in continence care How care should be delivered: Level 1: Community based staff Level 2: Specialist continence teams Level 3: Local MDTs Level 4: regional expert MDTs

Use of mesh for prolapse and incontinence surgery In Scotland concerns were raised about the number of women experiencing complications following insertion of trans vaginal mesh devices In Scotland concerns were raised about the number of women experiencing complications following insertion of trans vaginal mesh devices Suspended the use of polypropylene transvaginal mesh procedures Suspended the use of polypropylene transvaginal mesh procedures Now- not using transvaginal mesh Now- not using transvaginal mesh But are using vault support and sometimes hysteropexy But are using vault support and sometimes hysteropexy Common problems: Common problems: Pain Pain Removal of tape Removal of tape

Recent report: Recent report: Importance of MDT assessment, review and audit of the operations Importance of MDT assessment, review and audit of the operations Importance of informed consent- development of standard consent forms and patient information Importance of informed consent- development of standard consent forms and patient information Reporting of incidents and improved data collection- database of all surgeries performed Reporting of incidents and improved data collection- database of all surgeries performed

‘Scottish Independent review of the use, safety and efficacy of transvaginal mesh implants and treatment of stress urinary incontinence and pelvic organ prolapse in women’ ‘Scottish Independent review of the use, safety and efficacy of transvaginal mesh implants and treatment of stress urinary incontinence and pelvic organ prolapse in women’ Interim report: Interim report:

Take Home Messages…… Ask the question, don’t expect people to volunteer information about their incontinence Ask the question, don’t expect people to volunteer information about their incontinence Little, simple things can really improve QOL Little, simple things can really improve QOL Full assessment vital Full assessment vital Refer in to secondary care for more complex problems Refer in to secondary care for more complex problems