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

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

3. 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

4. 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

5. 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

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

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

9. 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
Just can’t wait toilet card (£5)

10. Management of Overactive Bladder

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

12. 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

13. 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

14. Which Anticholinergic?

15. 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!

16. Treatment of Stress Incontinence

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

18. 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

19. 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

20. 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!

21. 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

22. 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

23. Any Questions?
I can be contacted on: