Josh Karram PGY1 Riverside June 2016 Urinary Incontinence Josh Karram PGY1 Riverside June 2016

Overview Why it matters? Normal physiology Identify historical & physical traits to aid in diagnosis and classification of urinary incontinence Identify reversible causes of urinary incontinence Approach to treatment

Why it matters? Prevalence is high Affects quality of life More likely to: Have depression Limited social & sexual function Have increased dependence on caregivers

Normal Physiology Bladder fills  stretch receptors activated  signal sent via S2-S4  spinal cord  sensory cortex where need to void is perceived Threshold volume is reached (unique to the person) triggers awareness of need to void External urinary sphincter at bladder outlet stays contracted until ready to void; micturition inhibitory centre in frontal lobe also helps inhibit Decision made to void  signal to micturition centre  simultaneously contracts detrusor smooth muscle (via parasympathetic cholinergic nerve fibres) and relaxes internal sphincter (alpha sympathetic nerve fibres), striated muscles and pelvic floor

Normal Physiology CNS MSK/Anatomy

How do we classify incontinence? Typically broken down into 5 different categories Stress Urge Mixed Overflow Functional

Case 1 52 yo F G4P4 – all SVDs no complications/instrumentation BMI 30 Going through menopause Recently on health kick – wants to lose weight Certain exercises at gym causing her to leak urine Also noticed with coughing or laughing No urgency, frequency, dysuria, or nocturia Self-conscious Otherwise healthy; no medications

Stress Pathophysiology: Loss of urethral “support” (sphincter and/or pelvic floor weakness) allows for hypermobility and/or intrinsic sphincter deficiency Increased abdominal pressure leads to opening of urethra and leakage

Stress Risk factors Vaginal delivery Instrumental vaginal delivery Obesity Poor tissue Connective tissue disease, radiation, smoking, lack of estrogen, surgery Chronic cough Prostate surgery

Stress History Leaks during physical activity or increased intra-abdominal pressure: Coughing Laughing Sneezing Jumping Lifting Exercise Walking Rising from chair Usually starts as small volumes and can often predict when it will happen No nocturia Normal urge to void Normal voiding stream

Stress Physical Exam Pelvic exam Estrogen deficiency? atrophy Cough stress test Good sensitivity and specificity Full bladder (but comfortable) Separate labia, patient to forcibly cough once Supine +/- standing +ve if urine leaks with onset and cessation of cough Levator ani muscle strength – normally 5-10s Cough False positive if not enough urine/force; contraction of other pelvic muscles; obstructing prolapse Delayed 5-15 s may be stimulation of bladder from cough – urge

Stress Treatment Weight loss Fluid optimization Constipation management Smoking cessation

Stress Treatment Proper absorbent pads Pelvic floor muscle training Kegels Isolate muscles that stop urine flow 3 sets; 8-12 contractions; 8-10s each; 3x/day Vaginal weights Biofeedback Supervised pelvic floor physiotherapy

Stress Treatment con’t Continence pessary Surgery Midurethral sling – gold standard Tension free vaginal tape (TVT) or trans obturator tape (TOT) May also consider: Bladder neck sling Periurethral bulking Radiofrequency denaturation Bladder neck sling - reserved for women in whom mid urethral slings contraindicated/unsuccessful Bulking agents often for those wishing to delay surgery

Stress Medications Vaginal estrogen ring Vaginal estrogen cream Alpha adrenergic agonists (pseudoephedrine, phenylephrine) Increase resting urethral tone Weak evidence Duloxetine (Cymbalta) Incontinence reduction Not a good stand alone option but for depressed patient with concurrent stress incontinence, may be helpful

Case 2 41 yo G2P2 – SVDs no instrumentation Frequency & urgency – sometimes makes it; sometimes doesn’t Having to get up in the night 2-3x No dysuria Otherwise healthy Admits that she loves her coffee and wonders if that could be contributing

Urge Pathophysiology: Involuntary detrusor contractions during the filling of the bladder +/- full bladder 2 subtypes Sensory – result of local irritation, inflammation or infection Neurologic – most often caused by loss of cerebral inhibition of detrusor contractions

Urge Risk factors Irritation Loss of neurologic control cystitis, prostatitis, atrophic vaginitis, prior pelvic radiation therapy Loss of neurologic control Stroke, dementia, spinal cord injury, Parkinson’s

Urge History Examination Urgency, frequency, nocturia Usually normal Small or large volumes May be stimulated by change in body position or with sensory stimulation If they make it to the toilet – overactive bladder; if they don’t - urge incontinence Usually normal May consider urodynamic testing Cystoscopy if smokers or hematuria

Urge Treatment Lifestyle changes Review medications Caffeine elimination Weight loss Optimize fluid intake Smoking cessation Constipation management Review medications Pelvic floor strengthening – can be more effective than medications Bladder training Distraction Sacral nerve modulation Bladder training – finding natural interval then Try distraction Try prompted/scheduled toileting Sacral nerve stimulator – can be vaginal, anal or percutaneous of the posterior tibial nerve

Urge Medical therapy Anticholinergic medications – antagonize M2/M3 muscarinic receptors of bladder; selective/long-acting agents preferred Selective - darifenacin & solifenacin; non-selective - oxybutynin and tolterodine Increases storage, decreases urgency Side effects: dry eyes, dry mouth, constipation CI – narrow angle glaucoma, urinary retention, myasthenia gravis, dementia, GI obstruction/retention Beta-adrenergic agonists – mirabegron Relax detrusor; SE N/D, HA, dizziness, constipation, HTN Bladder Botox – lasts 3-6 months M2/M3 selective agents preferred; non-selective bind M1 receptors in brain and can unmask cognitive dysfunction Trial 4-8 weeks

Urge Surgery Implanted devices Stimulate sacral, paraurethral and pudental nerves Refractory to all other treatment Costly and risk of surgical complications

Mixed Stress Urge Mixed

Overflow Pathophysiology Urine loss associated with overdistension of bladder Typically by an underactive bladder and/or outlet obstruction Common example is benign prostatic hyperplasia

Overflow Risk factors Presentation Physical examination DM Spinal cord injury MS Bladder distension injuries Obstruction – prolapse BPH Anticholinergic medications Presentation Constant wetness/dribbling +/- urge +/- sensation of incomplete emptying Physical examination Wet vulva Palpable bladder High PVR – U/S scan vs I/O catheter

Overflow Treatment MRI if suspicious of MS Remove obstruction Clean intermittent catheterization Sacral nerve modulation MRI if suspicious of MS One of the earlier complaints for first presentation of MS

Functional Secondary to impairment Unable to make it to the toilet May be physical or cognitive Unable to make it to the toilet May also be in combination with previously mentioned etiologies Risk factors Dementia Physical frailty Inability to ambulate Mental health disorder

Putting it all together History HPI Urgency, frequency, nocturia Leakage with cough, sneeze, laugh, increased intra-abdominal pressure Constantly wet, dribble, incomplete void Dysuria PMHx Bowel, back, gynecologic or bladder surgery; pelvic radiotherapy CHF, COPD, neurological & MSK conditions, Prostate pathology Cognitive changes/functional abilities Constipation Gyne/ObHx Estrogen status, deliveries and type, time in between

Putting it all together Free tools available 3 incontinence questions – popular tool Categorizes urinary incontinence in middle-aged to older women Stress Sensitivity 0.86 Specificity 0.6 Urge Sensitivity 0.75 Specificity 0.77

Putting it all together Still not sure? Can also consider use of a voiding diary Short term may be as helpful as longer term – easier on you and the patient Help clarify situations, frequency, volume

Functional Inquiry Effects on: Work ADLs Sleep Sexual Activity Social interactions Interpersonal relationships General perception of health Quality of life Identify the most bothersome symptom – this will help direct management

Putting it all together MEDICATIONS! Recent changes? Some contribute by increasing urine production or impairing neuro functioning rather than having direct effect on urinary tract List from: Khandelwal, C., & Kistler, C. (2013). Diagnosis of urinary incontinence. American Family Physician, 87(8), 543-50.(9), 634-640.

Putting it all together Physical Exam CVS – arteriovascular disease; volume status RESP – chronic cough? GI – evidence of constipation, masses GU – bladder distension, vaginitis and atrophy, cough test NEURO – signs of stroke, impaired mental state, spinal stenosis, peripheral neuropathy; lumbosacral nerve root testing MSK – mobility DERM – irritation from incontinence

Transient Causes of Urinary Incontinence (DIAPPERS) Delirium Infection (acute UTI) Atrophic vaginitis Pharmaceuticals Psychological disorder, especially depression Excessive urine output Reduced mobility (e.g. functional) or reversible urinary retention (e.g. drug-induced) Stool impaction Sudden onset <6 weeks duration

Putting it all together Investigations Creatinine Urinalysis Urine culture MoCA Post void residual Recommended to diagnose overflow <50ml negative; 100-200ml indeterminate; >200ml positive U/S or I/O catheter

Diagnostic Approach Diagram from: Khandelwal, C., & Kistler, C. (2013). Diagnosis of urinary incontinence. American Family Physician, 87(8), 543-50.(9), 634-640.

Indications for Referral Associated recurrent symptomatic UTIs Associated new-onset neurologic symptoms, muscle weakness, or both Marked prostate enlargement Pelvic organ prolapsed past the introitus Pelvic pain associated with incontinence Persistent hematuria Persistent proteinuria Post void residual >200ml - obstruction Previous pelvic surgery or radiation Uncertain diagnosis

SAMP List 3 indications for referral of urinary incontinence

Indications for Referral Associated recurrent symptomatic UTIs Associated new-onset neurologic symptoms, muscle weakness, or both Marked prostate enlargement Pelvic organ prolapsed past the introitus Pelvic pain associated with incontinence Persistent hematuria Persistent proteinuria Post void residual >200ml - obstruction Previous pelvic surgery or radiation Uncertain diagnosis

SAMP List 3 causes of reversible urinary incontinence

Transient Causes of Urinary Incontinence (DIAPPERS) Delirium Infection (acute UTI) Atrophic vaginitis Pharmaceuticals Psychological disorder, especially depression Excessive urine output Reduced mobility (e.g. functional) or reversible urinary retention (e.g. drug-induced) Stool impaction Sudden onset <6 weeks duration

SAMP What non-pharmacologic treatment can be used for both urge and stress incontinence?

References Culligan, P. J., & Heit, M. (2000). Urinary incontinence in women: evaluation and management. American family physician, 62(11), 2433-44. Hersh, L., & Salzman, B. (2013). Clinical management of urinary incontinence in women. American family physician, 87 Khandelwal, C., & Kistler, C. (2013). Diagnosis of urinary incontinence. American Family Physician, 87(8), 543-50.(9), 634-640.