Urinary Incontinence Victoria Cook Consultant in obstetrics and Gynaecology The Hillingdon Hospital

Objectives Make a provisional diagnosis of cause of incontinence Formulate appropriate management plan When to refer Who to refer to

Incontinence in Women Major impact on quality of life Fear of cough / cold Stop exercising Avoidance of sex Fear of odour Worry about pads – cost, visibility, leakage Limitations of clothing Toilet mapping Housebound Yet may take years to present for help Embarassment Acceptance that it is normal after having kids

Definitions (ICS 2002) Over active bladder Urge incontinence Urgency with or without urge incontinence, usually accompanied by frequency and nocturia Urge incontinence Involuntary leakage accompanied by or immediately preceded by urgency Stress incontinence Involuntary leakage on effort or exertion or on sneezing or coughing

Urgency: The complaint of a sudden, compelling desire to pass urine, that is difficult to defer Frequency: Usually accompanies urgency with or without urge incontinence. Refers to a patient’s complaint of voiding too often by day Nocturia: Usually accompanies urgency with or without urge incontinence. Patient has to wake at night one of more times to void 1. Abrams P et al. Urology 2003;61:37-49

Stress Incontinence or Overactive Bladder? Leakage What makes her leak how much Pad usage Frequency of Micturition Nocturia Urinary Urgency Bedwetting Sex

Stress Incontinence or Overactive Bladder? Examination Abdominal mass Pelvic mass Prolapse Leakage seen on coughing Vulval hygiene Investigations MSU Frequency volume chart (Urodynamics)

Management of Urinary Incontinence Behavior modification Bladder retraining Weight loss Pelvic floor exercises Fluid management – what, when, how much Reduction in caffeine Bladder and bowel foundation www.bladderandbowelfoundation.org Just can’t wait toilet card (£5)

Management of Overactive Bladder

Treatment of Overactive Bladder Conservative measures Review all other medication which may be exacerbating symptoms Diuretics Amlodipine Other antihypertensives Anticholinergics Contraindicated with glaucoma (Botox)

NICE GUIDANCE Treat predominant symptom Oxybutynin Hydochoride Cheap Works well Side effect profile can be a problem All other anticholinergics have been developed to improve side effects Reasonable first line as long as patient aware there are alternatives Patient can be reviewed within 6 weeks to ensure they are tolerating the drug

Which Anticholinergic? (Detrusitol (tolterodine) 4mg XL) Vesicare (solifenacin) 5mg or 10mg Lyrinel (oxybutynin) XL 5mg, 10mg, 15mg or 20mg Kentera (oxybutynin) patches Emselex (darifenacin) 7.5mg or 15mg Toviaz (fesoterodine) 4mg or 8mg Regurin (trospium) 20mg twice daily

Which Anticholinergic?

Botox Unlicensed Seems to be very effective Multiple injections into the detrusor muscle via cystoscopy Evidence of long term safety in other disciplines But needs repeat injections approx 12 monthly Expensive!

Treatment of Stress Incontinence

Treatment of Stress Incontinence Life style advice Physiotherapy Duloxetine Surgery TVT Bulkamid bladder neck injections Colposuspension

Stress Incontinence Yentreve (duloxetine) Start at 20mg twice daily Increase to 40mg twice daily after 2 weeks This is to reduce side effects It is working at level of urinary sphincter NOT by reducing depression! Patients either love it or hate it

Surgery TVT Bulkamid Over night stay Good success rates 80-90% 2 weeks off work Risks of urgency, poor voiding, tape erosion Bulkamid Bladder neck injection – polyacrylamide hydrogel Day case / overnight stay Long term results unknown Useful in mixed incontinence, young, old, failed TVT

Mixed Incontinence Lifestyle advice Physiotherapy Treat overactive bladder Duloxetine can be very useful I try to avoid surgery as they do badly Now using Bulkamid – time will tell!

When to Refer Overactive bladder Stress incontinence Prolapse If patient not responding or unable to tolerate anticholinergic (oxybutynin plus one other) Glaucoma Stress incontinence If patient doesn’t respond to pelvic floor exercises (preferably with physiotherapist) Prolapse Other factors

Who To Refer To? Urogynaecology Both Urology Neurology Botox Prolapse Bladder pain Other pathology Urogynaecology Prolapse Fibroids Other gynae issues Both Stress incontinence Overactive bladder Recurrent UTI

Any Questions? I can be contacted on: victoria.cook@thh.nhs.uk