Urinary Incontinence in Women Dr Mangala Dissanayake

OBJECTIVES  Identify the various forms of Urinary Incontinence (UI) in females  To become knowledgeable about the treatment interventions available  To understand the impact of Urinary Incontinence

Prevalence of Urinary Incontinence 33% of women >65 have some degree of UI 26% of women>18 experience various degree of SI 15% to 30% of non-institutionalized older adults (19% men; 39% women) Prevalence increases with age and Menopause Incidents are more in female until the age of 80

Prevalence of UI

Incontinence in women – 19 billion dollars / yr “Silent Epidemic” Epidemiology

Urinary Incontinence is Often Under-Diagnosed and Under-Treated Only 32% of primary care physicians routinely ask about incontinence % of patients never describe symptoms to physicians 80% of urinary incontinence can be cured or improved.

Definition UI is the involuntary loss of urine that is objectively demonstrable and a social or hygienic problem. International Continence Society

Risk and Contributing Factors Age Parity Obesity Vaginal delivery Episiotomy ? Diabetes, BA, Chronic constipation Stroke Estrogen depletion Genitourinary surgery and radiation Depression,Dementia, Parkinson

Health Burden

Age and Menopause Detrusor overactivity (20% of healthy continent)  PVR,  nocturia,  UO later in day Atrophic vagintis & urethritis  ability to postpone voiding,  total bladder capacity,  detrusor contractility  urine concentrating ability,  flow

Consequences of UI Cellulitis, Pressure ulcers, UTI Sexual Problems Falls with fractures Sleep deprivation Social withdrawal, depression Embarrassment (50%), interference with activities  Caregiver burden, contributes to institutionalization Costs

Types of UI Transient UI (Acute) Established UI (Chronic) Urge UI Stress UI Mixed UI Overflow UI “Functional” UI

Prevalence in women Stress : 49% Urge : 22% Mixed : 29%

Transient UI (Acute) Lower urinary tract pathology Precipitated by reversible factors Causes: Delirium, UTI, Medications, Psychiatric disorders, Stool impaction Restricted mobility

Causes for Transient UI D Delirium I Infection A Atrophic Vulvovaginitis P Psychological P Pharmacologic agents E Endocrine, excessive UO R Restricted Mobility S Stool impaction

sedatives loop diuretics alcohol caffeine cholinergics (donepezil)  awareness,  detrusor activity  Func & O UI Diuresis overwhelms bladder capacity  Urge & O UI Polyuria,  awareness  Urge & Functional UI Polyuria,  detrusor activity  Urge  detrusor activity  Urge Culligan PJ Urinary Incontinence in women Evaluation and Management AFP Pharmacologic Causes

Physiology

Stress Urinary incontinence Involuntary loss of urine due to increase abdominal pressure without Detrusor contraction

Stress incontinence

STRESS INCONTINENCE Most common type in women in < 75 years old Occurs with increase in abdominal pressure- cough, laugh, sneeze, etc Hyper motility of bladder neck and urethra associated with aging, child birth, hormonal changes Intrinsic sphincter problems( pelvic irradiation, surgery, trauma, incontinence surgery) No urgency or nocturia

Treatment : Stress Incontinence Nonsurgical – Pelvic floor muscle training (Kegel’s) – Biofeedback – Electrical stimulation – Pessaries – Duloxetine is a selective serotonin and norepinephrine reuptake inhibitor.

Non Surgical Modest improvements – Pt’s with a small amount of leakage – Pt’s who want a conservative trial – Pt’s with significant comorbidities

Duloxetine Combined serotonin and noradrenaline reuptake inhibitor

Mechanism of action Increased synaptic concentration of noradrenaline and 5-hydroxytryptamine within the pudendal nerve results in increased stimulation of urethral striated muscles within the sphincter thus enhancing contraction. Increase sphincter activity in the storage phase of the micturition cycle

Authors’ conclusions Duloxetine Duloxetine treatment can significantly improve the quality of life of patients with stress urinary incontinence, but it is unclear whether or not benefits are sustainable Adverse effects are common but not serious. About one in three participants allocated duloxetine reported adverse effects (most commonly nausea) related to treatment, and One in eight allocated duloxetine stopped treatment as a consequence.

Authors’ conclusions Duloxetine Better than placebo Improved QOL May improve outcome in combination with pelvic floor training- Ghoniem 2005

Surgery A Burch Colposuspension C Tension-free Vaginal Tape B Fascial Sling

Stress Urinary Incontinence Less Invasive Surgery: Trans-obturator Tapes Anatomical landmarks Tape passes through medial edge of obturator foramen just below the insertion of the adductor longus tendon

Priurethral Injection for SUI

Objective cure rates for first procedure and recurrent incontinence 6 Stress Urinary Incontinence Surgical Treatment: Cure Rates

Urge Incontinence Incontinence accompanied by or immediately preceded by urinary urgency

Urge incontinence

URGE INCONTINENCE OAB, Detrusor instability, irritable bladder, detrusor hyperactivity. Most common UI > 75 years of age Abrupt desire to void urine cannot be suppressed Associated with frequency / nocturia. Causes- infection, vaginitis, tumor, stones, idiopathic ( Hormonal)

Urge incontinence

URGE INCONTINENCE

URGE INCONTINENCE Treatment  Patient education  Timed voiding  Habit training  urge inhibition  bladder training  Diet modification  Surgery  Local Oestrogen

URGE INCONTINENCE Treatment- Anticholinergic Drugs Oxybutynin Tolterodine Trospium Darifenacin Variety of preparations: Immediate Release; Extended Release; Transdermal Outcomes same; Try different agent if one doesn’t work. Continue for at least 4 weeks ***** ALL these drugs suppress the detrusor contractility and MAY CAUSE URINARY RETENTION!!! ALWAYS CHECK PVR PRIOR TO PRESCRIBING!!!

Antimuscarinic therapy

Side Effects 43%–83% of women abandon antimuscarinic therapy by 1 month At 1 year-35% women are still taking the medication

Mirabegron Beta-3 adrenoreceptor agonist Promotes relaxation of the detrusor muscle – Reduce incontinence episodes – Reduced urgency – Reduced frequency Vs placebo (pooled data of 3 phase III RCTs) US Food and Drug Administration (FDA) approved in 2012

HRT and UI Conclusion At present, systemic HRT administration should not be recommended for treatment or prevention of UI in postmenopausal, especially older, women. Urinary incontinence may be improved with the use of local oestrogen treatment

URGE INCONTINENCE Refractory to Treatment

OVERFLOW INCONTINENCE  Over Distension of Bladder  Bladder outlet obstruction- Stricture, Cystocele, fecal impaction  Non contractile bladder- Diabetes, Spinal injury.  Filling occurs to the stretch limit of the bladder  Large PVR >400cc  Dribbling, frequency  High rates of infections

Pessary

OVERFLOW INCONTINENCE Obstruction—Treat cause;  -antagonist- Tamsulosin, Prazosin Detrusor Underactivity intermittent self- catheterization Bethanechol ( used to treat underactive detrusor function with elevated PVR)  Patient education  “Double voiding technique”  Diet modification  Avoid caffeine/alcohol  Barrier product to prevent skin breakdown  Reassess the Medication

OVERFLOW INCONTINENCE Tamsulosin Efficacy and Safety of Tamsulosin for the Treatment of Non- neurogenic Voiding Dysfunction in Females: A 8-Week Prospective Study Tamsulosin was found to be effective in female patients with voiding dysfunction regardless of obstruction grade.

Tamsulosin Vs Prazosin in OI Tamsulosin and prazosin are both effective in palliating symptoms of women with voiding dysfunction and improving their urodynamic parameters. Tamsulosin may be the preferred drug to prescribe because of its more amenable side effect profile and greater patient satisfaction.

Features of both urge and stress incontinence. Common in older women 4-55% mixed type of UI Management: bladder retraining, pelvic muscle exercises, Diet Modifications pharmacologic agents- Antichloinergic, Imipramine Mixed Incontinence

MIXED INCONTINENCE

“Functional” Incontinence Unable or unwilling to toilet due to physical impairment, cognitive dysfunction, environmental barriers No underlying GU dysfunction Diagnosis of exclusion

EVALUATION OF INCONTINENCE  History  Physical exam ( including Neuro and abdominal, pelvic and rectal examination)  Clinical testing- Stress test, PVR by catheterization or ultrasound.  Laboratory testing- UA, Urine culture, FBS,B Urea.  URODYNAMIC TESTING

Cesarean Section Vs UI Pregnancy per se increases UI, irrespective of mode of delivery Elective/ Pre labour Cesarean section has low incidents of UI in Post partum period Advantage disappears with age and in subsequent pregnancies